HPV Vaccine Standing Orders and Communication in Primary Care: A Qualitative Study

Abstract

Background.

Standing orders may improve HPV vaccination rates, but clinical staff’s readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups.

Methods.

Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis.

Results.

Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses’ and medical assistants’ confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible.

Conclusion.

Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.

Introduction

Human papillomavirus (HPV) vaccination prevents six cancers (cervix, anus, mouth, throat, head and neck).^1,2 In the United States (U.S.), Black, Indigenous, and Latino communities have higher disease burden, lower survival rates, and higher rates of HPV-associated cancers.^3,4 As of 2020, 75% of adolescents ages 13–17 years received at least one dose of HPV vaccine, and 59% were up-to-date nationally.⁵ Black and Latino children are less likely to be up to date with HPV vaccination, although they have higher initiation rates than Non-Hispanic White children.^6–8 HPV vaccination coverage is increasing, but it remains below the Healthy People 2030 goal of 80% of adolescents ages 13 to 15 being up to date, and it falls behind other routine adolescent immunization rates.^5,9 National organizations use different framing for HPV vaccine recommendations at age 9. For example, the Centers for Disease Control and Prevention (CDC) recommends that HPV vaccination should start at ages 11–12 but can start at age 9.¹⁰ However, the American Academy of Pediatrics recommends routine HPV vaccination starting at age 9 to increase HPV vaccine series completion by age 13 and reduce the number of concurrent vaccinations at age 11 or 12.²

Earlier initiation of HPV vaccination is associated with higher vaccine series completion rates by age 13 in many studies without waning affects,^11–16 and healthcare providers were willing and accepting to vaccinate children at age 9.^17–20 Greater provider knowledge of HPV vaccination, making recommendations for HPV vaccination, and including perceived susceptibility about HPV in messaging can facilitate vaccine uptake.²¹ However, inconsistent engagement, provider discomfort with sexual health-related conversations, and perceived parental hesitancy create challenges for providers to promote HPV vaccination in earlier adolescence.²² Clinical strategies such as provider communication training, providing electronic medical record (EMR) support, standardized posters or printed resources, using vaccine champions, reminders, incentives, and targeted HPV education have shown promise in improving HPV vaccination among adolescents.^18,23–24

Promoting early HPV vaccination is especially important, given that use of preventive health services decreases as U.S. adolescents increase in age.²⁵ Racial and ethnic marginalized adolescents are particularly underserved due, in part, to being less likely to have a usual place for preventive care.^26–28 However, visits for non-preventive care rose to 1.5 visits per year among older adolescents.²⁷ Standing orders may offer the potential to address vaccination disparities by reducing missed opportunities to recommend and administer HPV vaccine to eligible children during all clinic encounters, extending beyond preventive visits.

Standing orders authorize clinical staff such as nurses and medical assistants to “assess a client’s immunization status and administer vaccines according to a protocol approved by an institution, physician, or other authorized provider without an examination or direct order from a health care provider.”^29–30 Standing orders exist for other childhood vaccines, and using them increases vaccination rates.^31–35 Despite national health organizations’ recommendations to use standing orders to reduce missed opportunities for vaccination,³⁶ vaccine standing orders are often underused for childhood vaccination. Among a national sample of pediatricians, 41% did not use them at all for routinely administered vaccines.³⁶ Standing orders use for HPV vaccination is emerging within healthcare systems, however, few studies have investigated clinical staff’s readiness to use HPV vaccine standing orders in practice. Using HPV vaccine standing orders holds promise for improving HPV vaccination uptake and may provide nurses and medical assistants more autonomy within their roles in HPV vaccination. The purpose of this study was threefold: (1) to explore benefits and challenges to clinical staff use of HPV vaccine standing orders for adolescents ages 9 to 12 years, (2) to understand clinical staff roles in HPV vaccine communication with parents, and (3) to explore how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups.

Methods

Participants and Setting

Participants were recruited from June 2022 to September 2022 via email using a list of former participants interested in research opportunities or through referrals from the study team’s professional networks. Eligible participants were U.S. providers (e.g., physicians, advanced practice practitioners), nurses, and medical assistants who had roles in HPV vaccination for children ages 9–12 and worked in clinics that did not have HPV vaccine standing orders for children ages 9–12, were unsure about their use, or used them to varying degrees (never, rarely, sometimes, frequently, or all the time). Inclusion criteria required two clinical staff members to enroll per clinic. If a provider was interested in participating, they had to identify a nurse or medical assistant from their clinic; similarly, a nurse or medical assistant had to identify a provider.

Procedures

Interviews were conducted separately by three researchers, one with qualitative expertise (first author) and two graduate research assistants who were trained by the first author in conducting qualitative interviews and analyses. Verbal consent was obtained prior to the start of the interviews, and participants received a $100 electronic Amazon gift card for study participation. All interviews were conducted using Zoom³⁷ and were audio-recorded and professionally transcribed. Exempt study approval was obtained from the University of North Carolina Institutional Review Board.

Interview Guide

The interview guide was developed based on previous literature on standing orders use for vaccination and incorporated feedback from a clinical advisory board consisting of experienced physicians, advanced practice practitioners, nurses, and medical assistants. The qualitative interviews were designed to characterize the role of nurses and medical assistants in HPV vaccination and communication. Health care providers were included in interviews to gain perspectives on their role in collaborating with nurses and medical assistants in HPV vaccination, communication, and standing orders use. Questions were organized by HPV vaccine standing orders use for children ages 9–12 (e.g., yes or no/not sure) and explored benefits and challenges of using standing orders for HPV vaccination in clinic, as well as the role of nurses and medical assistants in HPV vaccine communication. HPV vaccine equity questions asked about racial and ethnic disparities in HPV vaccine uptake among Black and Latino children and challenges to vaccine access. Participants were asked to reflect on clinical experiences with HPV vaccination among these populations and identify perspectives on why they believed these vaccination disparities exist (Supplemental Table 1). Participants completed an online demographic survey at the completion of the interview to describe sample characteristics.

Data Analysis

Transcripts were analyzed using reflexive thematic analysis³⁸ in Atlas.ti, version 22.³⁹ Transcripts were read in entirety so that the research team could become familiarized with the data and identify essential features. An open coding approach was used to develop the initial coding scheme. Initial coding was performed by two coders and a researcher with qualitative methods expertise who reviewed two transcripts to compare and validate emerging codes and develop a preliminary codebook. After code review and validation, codes were added or revised through an iterative code-recode process until consensus was reached among all coders. Analytic memos were recorded to capture the research teams’ thoughts and reflections of emerging codes. Codes were grouped into categories based on pattern similarities within the data, then themes were created based on relationships, consistent patterns, and inconsistencies across each category through an iterative process. After reaching consensus among the coding team with the emerging themes, overarching themes were defined that best described the patterns in the data when no new relationships were identified. Descriptive statistics were conducted to analyze participants’ characteristics obtained in the demographic surveys.

Results

Sixteen clinical staff members participated in interviews, including 6 physicians (38%), 2 advanced practice providers (13%), 4 nurses (25%), and 4 medical assistants or certified nursing assistants (25%) (Table 1). Most participants practiced in pediatrics clinics (63%) and in group practice settings (56%) across five U.S. states. Participants were from 8 clinics that used HPV vaccine standing orders frequently (k=4 clinics), used them sometimes, rarely or never (k=2), and did not have standing orders for HPV vaccination (k=2).

Table 1.

Participant Demographics

Characteristic	n (%)
PARTICIPANT
Training
Physician	6 (38)
Advanced practice provider (APN, PA)	2 (13)
Nurse (RN, LPN, LVN)	4 (25)
Medical assistant or certified nursing assistant	4 (25)
Gender
Man	2 (13)
Woman	14 (88)
Race/ethnicity
Asian	1 (6)
Black or African American	1 (6)
Hispanic or Latino	4 (25)
White	9 (56)
Multiple	1 (6)
Years in practice
0–9 years	9 (56)
10–19 years	5 (31)
20+ years	2 (13)
CLINIC
Region
Northeast	2 (13)
South	8 (50)
West	6 (38)
Clinic specialty
Family medicine	6 (38)
Pediatrics	10 (63)
Clinic type
Federally Qualified Health Center	2 (13)
Group practice	10 (63)
Hospital or academic institution	4 (25)
HPV vaccine standing orders use a
Never, rarely, or sometimes	4 (25)
Frequently or always	9 (56)
Did not have or was not sure	3 (19)

^aOne physician-nurse pair from the same clinic reported a difference in response of their clinic's standing order use. APN=Advanced practice nurse, PA= Physician assistant, LPN=Licensed practical nurse, LVN=Licensed vocational nurse, RN=Registered nurse.

Clinical staff described their clinic’s use of HPV vaccine standing orders and their role in HPV vaccine communication. Identified themes are organized by benefits and challenges to using HPV vaccine standing orders and using HPV vaccine standing orders to improve HPV vaccine communication and vaccine access at clinics (Table 2).

Table 2.

Themes and Quotes on HPV Vaccine Standing Order Use and Strategies to Improve Vaccine Access and HPV Vaccine Communication Among Clinical Staff

Benefits of Using HPV Vaccine Standing Orders
Themes	Relevant Quotes
Faster and efficient clinic flow	“If [the standing order] can just be already in…it’s one less step for any other person to put in. If [the standing order] comes up, and parents who may have questions about the HPV vaccine or any concerns…it’s just an additional touchpoint for them to be able to have a conversation with an additional person who maybe isn’t the provider.” -#HPV103, pediatrician, clinic rarely/sometimes uses HPV vaccine standing orders “[Standing orders] facilitates [clinic flow] because [clinical staff are] going into the patient’s [room] first so it’s almost like giving the parent an advanced notification and a little bit of time before [the provider is] coming in to either ask specifically or give the go ahead [to give the vaccine]. [It] probably assists with flow…If they’re [the parent is] going to have an issue with a vaccine, you know it by the time you go into the room.” -#HPV109, physician assistant, clinic frequently uses HPV vaccine standing orders
Fewer missed opportunities for HPV vaccination and promotion of early vaccine initiation	“It helps the patient with being vaccinated earlier and not waiting until they’re 11 and 12 years old, getting multiple vaccines at that visit, along with their Tdap and meningococcal, so it helps…lessens how many [shots] they get at their visits.” -#HPV101, medical assistant, clinic frequently uses HPV vaccine standing orders “It allows for additional opportunities for it [HPV vaccine] not to be missed. It’s another almost catch safeguard for anyone who may be overlooking anything, be it a provider, whoever else [and] can likely increase the likelihood of higher vaccination rates. -#HPV103, pediatrician, clinic rarely/sometimes uses HPV vaccine standing orders
Normalization of HPV vaccination as routine care	“[Standing orders] makes [HPV vaccine] the same. I think the point is it normalizes it. It’s no different than any other immunization. I think that’s the important part. For anything, it’s no different than any other.” -#HPV110, family medicine physician, clinic frequently uses HPV vaccine standing orders “By having [the HPV vaccine standing order] being presented to the parent right from the get-go as a vaccine that’s done regularly kind of shows the confidence in the vaccine…because if you come at it with, ‘there’s this extra vaccine’…you’re approaching it as an add-on [and] I feel like that would show maybe less confidence.” -#HPV109, physician assistant, clinic frequently uses HPV vaccine standing orders
Challenges of Using HPV Vaccine Standing Orders
Themes	Relevant Quotes
Possible exacerbation of existing HPV vaccine communication and recommendation barriers	“When it’s not the provider initiating that conversation or it’s not driven by the provider initially, parents give more pushback…sometimes parents will always say, ‘Well, that [HPV vaccine] hasn’t been out very long,’ if they [medical assistants] can’t come right back and say, ‘Well, actually, it’s been on the market for 17 years and here’s the different manufacturers and here’s the safety profile…’… [if one of our CMAs] can’t answer those questions, then sometimes that gives parents a little bit of concern.” -#HPV109, physician assistant, clinic frequently uses HPV vaccine standing orders “I want to make sure [the parent’s] questions are answered before [they] actually accepting the vaccine. If there is that standing order, and they come in and they have questions, it’s very unlikely that there would be time to discuss that when they are actually there. And by the time for turnaround on that may not be until either later that day or the following day.” -HPV#100, family medicine physician, clinic frequently uses HPV vaccine standing orders
The complexity of the vaccine administration schedule lessens nurses’ and medical assistants’ confidence to use HPV vaccine standing orders	“The nurses really don’t know the schedule or what is recommended and at what age…When I would ask them, ‘Hey, do you know the schedule?’ or ‘Hey, do you know at what age I can’t give this vaccine at?’, they always say that they don’t know.” -#HPV111, medical assistant, clinic frequently uses HPV vaccine standing orders “Getting the timeframe right [would be a challenge of using HPV vaccine standing orders] …I think one is a month after and the other one could be six months from the first one. It’s so confusing…” -HPV#115, licensed practical nurse, clinic without HPV vaccine standing orders
Using standing orders to improve HPV vaccine communication and HPV vaccine access at clinics
Themes	Relevant Quotes
Nurse-only visits: An opportunity to empower nurse autonomy and catch-up on HPV vaccination	“I could see [HPV vaccine standing orders] being most helpful when patients come in for a nurse visit. There are a fair number of things that people come in for just a nurse visit […] So, if they were able to give HPV vaccine when somebody was eligible at that visit, that would be helpful… We would be able to sort of capitalize on that ability to give an HPV vaccine that day, which they can’t do now without talking to the provider first.” -#HPV114, pediatrician, clinic without HPV vaccine standing orders
Engaging clinical staff to follow-up with children overdue for HPV vaccination	“We do those recalls to call parents and remind them ‘hey, your child is past due one month, it’s time for you to do a check-up’ or even recalls for parents who child’s physical is coming right up…We have our schedule open six months ahead [to] do a recall for those parents who have not scheduled their appointments…” -HPV#107, medical assistant, clinic frequently uses HPV vaccine standing orders
Educating parents on HPV vaccine before their child is vaccine eligible	“Early education to parents of younger children [would be helpful], so that way when they turn 9 and 10, and we’re having those conversations, they’ve started to hear it a little bit. And then when they’re like, 10, 11, 12, they’re more prepared.” -#HPV104, family medicine physician, clinic rarely/sometimes uses HPV vaccine standing orders “The pediatricians start talking to the parents, usually by the age of eight or so, saying, ‘hey, here’s something to think about, this is something that’s upcoming, they’re getting close to the age, better to start up before they’re sexually active.’ And try to get [parents] on board to [get their child vaccinated] ahead of time.” -HPV#105, licensed practical nurse, clinic rarely/sometimes uses HPV vaccine standing orders

Benefits of Using HPV Vaccine Standing Orders

Faster and efficient clinic flow

Clinical staff reported that having standing orders for HPV vaccine readily in place reduced the time spent waiting to obtain an order from a health care provider for HPV vaccination, creating a faster clinic flow for nurses and medical assistants to administer HPV vaccine and making visits quicker for patients. A medical assistant at a clinic without HPV vaccine standing orders shared that if they had them, “[It would be] faster for the patient…They don’t have to wait while I go find a doctor to go get the order. I’d be able to order that myself.” Clinical staff also perceived having standing orders as an opportunity to initiate communication about HPV vaccine with parents earlier in the clinic visit, improving efficiency in the clinic flow. One provider at a clinic that frequently used HPV vaccine standing orders stated, “I think it makes it more efficient in general to have the standing order already there. If a patient’s parent is fine with it, then they can just kind of get it done and out of the way […] if they have more questions, at least the conversation was already started, so when I go in, I can just focus on the questions.”

Fewer missed opportunities for HPV vaccination and promotion of early vaccine initiation

Clinical staff felt that using HPV vaccine standing orders would increase HPV vaccine uptake because the standing orders would help staff “catch” children needing HPV vaccine during a visit, thus lessening missed opportunities. Among clinics frequently using standing orders for all childhood vaccines, a nurse practitioner stated that they were often used to serve as a reminder for providers and clinical staff to “visually check to make sure we go back manually to the vaccine list and check that they’ve been completed.” Clinical staff also expressed that HPV vaccine standing orders provide opportunities to initiate vaccination at earlier adolescent ages and incentivize parents to start vaccination earlier to reduce the number of doses needed for vaccine completion. A medical assistant at a clinic frequently using HPV vaccine standing orders shared their approach to encourage parents to start HPV vaccination earlier, stating, “Having [standing orders] for HPV reminds us that we need to ask parents…’If you have [your child] get it now, they’ll only get two doses, but if they get it later on, they’re going to have to get the third one.’”

Normalization of HPV vaccination as routine care

Clinical staff shared that HPV vaccine tends to stand out from other childhood vaccines and typically generates more concerns and questions from parents, creating challenges with communicating HPV vaccination to hesitant families. They expressed hope that HPV vaccine standing orders would reduce parents’ concerns because they believed it will normalize HPV vaccine as routine care for adolescent health. One physician at a clinic that did not use HPV vaccine standing orders stated, “I do think it could give parents the reassurance [that HPV vaccination] is a very routine thing. No one refuses to take vitals…it’s just something that happens to everyone. If [HPV vaccine] was put in the light of just being routine, in that nurses can offer it, give it and then be done with the visit, I think could ease parents’ concerns because there wouldn’t be any [communication] barriers like, ‘Are you sure you want to get it…,’ which maybe would signal, oh, is this not normal?”

Challenges of Using HPV Vaccine Standing Orders

Possible exacerbation of existing HPV vaccine communication and recommendation barriers

HPV vaccine communication barriers among clinical staff included lengthy discussions in a time-restricted clinic visit, difficulty promoting a non-school mandated vaccine to parents, and the need to address parents’ beliefs that the HPV vaccine is associated with sexual debut. Clinical staff reported not having enough time to address parents’ concerns, fearing that using HPV vaccine standing orders may exacerbate these existing communication barriers, especially for nursing staff. A physician at a clinic without HPV vaccine standing orders shared that if they had them, “The nurses would be the ones fielding most of the questions until maybe passing it on to the physicians. They [may] feel [that] because of a standing order for HPV…they have to answer more questions than they would typically…and maybe that would take more time for them...” Because standing orders can initiate HPV vaccine discussions at any point during a clinic visit, clinical staff were also concerned about raising skepticism among parents if HPV vaccine was offered by a nurse or medical assistant before parents spoke with the health care provider first.

Health care providers reported that using their own individualized approach to recommend HPV vaccine created challenges in making strong vaccine recommendations and contributed to inconsistencies in the way providers approach age-specific recommendations for HPV vaccination. One physician at a clinic without HPV vaccine standing orders reported: “I always recommend starting at 9 years old…it used to be at 11 and so some [providers] do it then…some start girls earlier than boys, like girls at 9 and boys at 11.” Providers acknowledged that solely using HPV vaccine standing orders was not enough to address these recommendation inconsistencies and requested a standardized approach to assist providers in using consistent language in recommending HPV vaccination to families. One physician at a clinic frequently using HPV vaccine standing orders expressed, “[Providers] introduce [HPV vaccine] in a way that [is] different… [it’s a] benefit of them trying to move towards an announcement approach as it moves it more to a standardized [vaccine], more the way that we deal with non-stigmatized vaccines.”

The complexity of the vaccine administration schedule lessens nurses’ and medical assistants’ confidence to use HPV vaccine standing orders

Although nurses and medical assistants can provide patient education within their scope of practice, some felt unprepared to answer questions about the HPV vaccine schedule and number of doses needed based on a child’s age at vaccine initiation. Among clinics that rarely used HPV vaccine standing orders, uncertainty in the vaccine schedule made some nurses and medical assistants feel less confident in their ability to use HPV vaccine standing orders if their clinic were to adopt them. One nurse at a clinic without HPV vaccine standing orders shared concerns about navigating the vaccine schedule if they had them, stating, “Not everyone is comfortable figuring that [vaccine timeframe] out…it depends on when you start and what the timeframe [is]…it’s so confusing…especially for the new nurses.” For clinics that used HPV vaccine standing orders frequently, lacking clinic policies supporting standing orders use for HPV vaccination at age 9 in the EMR further created confusion about HPV vaccination by age. A medical assistant at a clinic frequently using HPV vaccine standing orders expressed, “Our clinic policy [states] that we don’t start the vaccine until age 11… But we [can] override it because the CDC requires it and recommends it that early [age 9]. But our EMR, it’s going to flag us and let us know like, “Hey, this is too early for this patient.”

Using standing orders to improve HPV vaccine communication and HPV vaccine access at clinics

Clinical staff acknowledged that both external structural barriers and clinic barriers impacted access to HPV vaccination, including a lack of access to transportation, difficulty scheduling appointments due to parents’ work schedules, and health insurance coverage. Many of these barriers were exacerbated by the impact of the COVID-19 pandemic. For example, scheduling appointments became particularly difficult for families in which parents were essential workers and taking time off work or providing childcare became exceedingly difficult. Clinical staff offered potential solutions on how standing orders can be used to address some clinic barriers (described in subthemes).

Nurse-only visits: An opportunity to empower nurse autonomy and catch-up on HPV vaccination

Clinical staff perceived the use of HPV vaccine standing orders as way to empower nurses to optimize their autonomy by practicing at the top of their license. One physician, whose clinic did not have standing orders, stated that if they had them, “…it would empower the nurses and would probably improve their job satisfaction […] if there are standing orders, and the nurses are saying you’re due for this today, and they have scripting for that, it’s just another strong message to the family that this is just something that we do.” Clinical staff also saw having HPV vaccine standing orders as an opportunity to offer nurse-only appointments that would enable nurses to manage a vaccine clinic. This would allow nurses to administer HPV vaccine without the presence of a health care provider and provide children the ability to receive HPV vaccine doses outside of well-child visits. Clinical staff saw these visits as an opportunity to expand clinic hours (e.g., after hours, weekends) and keep children up to date with HPV vaccine and other childhood vaccines. A nurse at a clinic without HPV vaccine standing orders reflected on a time when they worked at another clinic offering nurse-only visits, sharing, “Every Monday we would have an HPV clinic along with our nurse visits…it’s to catch up everybody on HPV [vaccination].”

Engaging clinical staff to follow-up with children overdue for HPV vaccination

Clinical staff highlighted that using EMR prompts with HPV vaccine standing orders was effective in identifying overdue patients. Those frequently using HPV vaccine standing orders described how prompts in the EMR and patient portals flagged children overdue for HPV vaccination, reminding clinical staff to follow up with them to schedule appointments. In these cases, standing orders for HPV vaccine were automatically generated into the patient’s chart so that clinical staff could use them at the next clinic visit. One nurse at a clinic frequently using HPV vaccine standing orders shared that in the EMR, “The [HPV vaccine] dose will turn red when it’s due. It lets you know that it’s available to be done. [I’ll let parents know], ‘Hey actually, your [child is] due for this. When you come in for this, let’s go ahead and [get the HPV vaccine].’” Clinical staff also expressed increasing clinic scheduling efforts to follow up with children overdue for vaccines. One physician assistant at a clinic frequently using HPV vaccine standing orders described how their healthcare system has a dedicated staff member to focus on timely vaccination: “Our vaccine coordinator…pick[s] up all those patients who are flagged for missing a vaccine…[their] job is to create a reminder in the chart, so that way, even if that patient comes in for a sick visit, we can get that vaccination series completed.”

Educating parents on HPV vaccine before their child is vaccine eligible

Clinical staff perceived the use of HPV vaccine standing orders at ages 9–10 as an opportunity to begin earlier discussions and education on HPV vaccine with parents. Many felt that parents may be more willing to accept HPV vaccine if they received information before their child was eligible to receive it and were given time to decide. A medical assistant at a clinic frequently using HPV vaccine standing orders suggested, “[We should] say, ‘Hey, these are vaccines that are going to be eligible when [your child is] coming in for the 9-year checkup, 10-year checkup […] just so that they can actually get the right type of information that is needed to make an informed decision.” Clinical staff requested additional resources (e.g., brochures or pamphlets) that addressed topics on the importance of vaccinating children at age 9 and parents’ vaccine concerns around gender, fertility, and sexual debut.

Discussion

This qualitative study of clinical staff in primary care identified clear benefits and potential challenges to using HPV vaccine standing orders and communicating about HPV vaccine with families. Clinical staff perceived HPV vaccine standing orders as being beneficial to improve clinic flow efficiency, reducing missed opportunities for HPV vaccination in younger ages, and normalizing HPV vaccination as routine care. However, clinical staff thought that HPV vaccine standing orders could exacerbate existing vaccine communication and recommendation barriers and reduce nurses’ and medical assistants’ confidence in using them due to their uncertainty about the vaccine administration schedule. Participants described strategies to address HPV vaccine access barriers in using standing orders, including identifying and following up with children overdue for vaccination, improving vaccine education resources and communication practices for vaccine eligible children, and empowering nurse autonomy to manage nurse-only visits for recommended doses and catch-up vaccination.

Clinical staff in this study expressed optimism in using HPV vaccine standing orders but perceived challenges to using them successfully due to the difficult nature of communicating about HPV vaccine with parents. Successfully engaging clinical staff to use HPV vaccine standing orders will require assessing staff readiness to discuss HPV vaccination with parents, use standing orders, and clearly demonstrate to staff that standing orders use will improve clinic barriers. Previous research has explored clinical staff engagement around vaccination standing orders, but not for pediatric HPV vaccination, and found that training justified the importance of standing orders use for clinical staff and empowered them to act with greater clinical autonomy.⁴⁰ However, HPV vaccination was highlighted as a particularly challenging vaccine for standing orders use because of the communication challenges it presented.⁴⁰ Lack of incentive for clinical staff decreased engagement to use standing orders.⁴¹ To engage and encourage clinical staff to use HPV vaccine standing orders, healthcare systems will need to provide additional support that addresses clinic barriers around HPV vaccine communication, such as improving HPV vaccine messaging for younger ages and providing vaccine education that addresses parents’ concerns.

Using HPV vaccine standing orders presents an opportunity to promote nurse autonomy for vaccination and engage nurses to address HPV vaccine access barriers. Registered nurses can assess patients, perform physical exams, identify potential diagnoses and health outcomes for an individualized plan of care, coordinate care, and educate and counsel patients and families within their scope of practice,⁴² which are necessary tasks for administering HPV vaccine. Using standing orders further promotes nurses’ autonomy, allowing them to operate at the highest level of their licensure and manage nurse-only visits for vaccination. Nurse-only visits may be an effective strategy to reduce missed opportunities for HPV vaccination and help unvaccinated or under-vaccinated children who infrequently utilize preventive care (e.g., well-child visits) to catch up on childhood vaccines.^43–44 However, nurses in this study reported lacking confidence in using standing orders due to perceived complexity with the HPV vaccine administration schedule. This finding underscores the importance of integrating HPV vaccine education with clinic support for standing orders use so that nurses can increase their confidence in using HPV vaccine standing orders and become more autonomous in their roles in HPV vaccination.

Participants identified potential barriers to HPV vaccine communication in the context of standing orders, including time constraints and parental hesitancy if a provider does not initiate the conversation about HPV vaccine. These concerns mirror previous research on the use of standing orders in pediatric settings.³⁶ They also highlight the need for a more standardized approach to making HPV vaccine recommendations, which aligns with important aims of related communications research on HPV vaccination. The Announcement Approach Training (AAT), which teaches an evidence-based presumptive communication approach to standardize HPV vaccine recommendations, has been found to increase HPV vaccination rates⁴⁵ and was recently updated to incorporate language for children ages 9–10.⁴⁶ Using tools such as the AAT to teach health care providers and clinical staff how to appropriately discuss HPV vaccination with families offers an important step towards standardizing communication and educating families. Including community perspectives on vaccine acceptance and use of preventive care services is also needed to understand and address vaccine access barriers and tailored HPV vaccine communication for racially and ethnically diverse populations.^47–48 To ensure more consistent HPV vaccine recommendation practices, it is critical for national organizations to align language on starting HPV vaccination at age 9, given current inconsistencies among groups such as the CDC and American Academy of Pediatrics.¹⁷ Changes in HPV vaccine practices should also be reflected in clinic policies for age parameters set in the EMR to support clinical staff in administering HPV vaccine beginning at age 9.

This study has several limitations. First, generalizability is limited by use of convenience and snowball sampling, mostly comprised of a small sample of physicians and nurses who worked in clinics primarily located in large healthcare systems in urban and suburban areas in five U.S. states. Thus, the applicability of the study findings remains to be established for clinics in rural areas or other states and for other health care professionals (e.g., physician assistants or nurse practitioners), who may have provided a deeper understanding of other clinical staff roles in HPV vaccine standing order use and identified differences among roles. Additionally, we did not assess community perspectives about HPV vaccine hesitancy and use of preventive care services, which could have provided deeper insight into vaccine access barriers and specific topics parents would want to discuss in HPV vaccine communication. Second, despite the small sample in this study, we reached thematic saturation with the included participants. Third, most participants worked in clinics that used HPV vaccine standing orders. This allowed the investigators to understand the use of HPV vaccine standing orders but limited the ability to explore barriers associated with adoption because clinics had long-standing, established standing orders for HPV vaccination prior to study participation. Fourth, we did not obtain HPV vaccination rates for each participating clinic, which could have provided additional insight into whether reported access barriers played a role in clinic vaccination rates among Black and Latino children. Lastly, we were unable to make causal claims from this study. Nonetheless, this study highlights important benefits and challenges to HPV vaccine standing orders use, as well as implications for clinics considering adopting and implementing them in practice.

Conclusion

Using HPV vaccine standing orders holds promise for improving HPV vaccination in early adolescence and addressing some clinic structure issues contributing to vaccine access barriers. Greater autonomy for nurses and medical assistants using HPV vaccine standing orders can expand their roles in practice, such as managing nurse-only visits for catch-up vaccination for children overdue on vaccines. However, it is critical that nurses and medical assistants are empowered to perform at the highest level of their licensure and supported with necessary HPV vaccine training and education (e.g., reviewing the vaccine administration schedule and guidelines) to be more autonomous within their role in HPV vaccination. Health care providers may also benefit from HPV vaccine communication training to standardize vaccine recommendations and improve communication about HPV vaccine with families. This study highlighted that maximizing the use of HPV vaccine standing orders by clinical staff will require healthcare systems to engage and support staff to use HPV vaccine standing orders, minimize excessive changes to clinic flow, and mitigate existing vaccine communication barriers.