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