“The big topic is COVID”: A qualitative study about changes in HPV vaccine conversations between parents and primary care team members throughout the COVID-19 pandemic
In 2006, the human papillomavirus (HPV) vaccine was approved for use in the United States (US) for the first time with a quadrivalent version. A bivalent HPV vaccine was then approved for use in 2009. In 2014, a 9-valent HPV vaccine was also licensed in the US, providing protection against five additional cancer-causing HPV strains not covered in the bivalent and quadrivalent vaccines. Provider recommendation for the HPV vaccine has been identified as one of the strongest predictors for vaccination to take place. For instance, HPV vaccine initiation (receiving at least one dose) is 10 times more likely to occur in the US among parents that report receiving a provider recommendation. Since the initial HPV vaccine approval in 2006, providers have indicated that parental attitudes and concerns toward the vaccine are barriers to accepting the HPV vaccine for their children, even after receiving a provider recommendation during conversations in primary care. , In response to these barriers, communication interventions such as the Announcement Approach have been developed in the US to improve provider communication practices to better engage in HPV vaccine conversations with parents. The emergence of the COVID-19 pandemic in 2020 created unprecedented challenges for vaccine delivery and communication in the US. Initial disruptions to routine health-care services led to significant decreases in HPV vaccine administration, with a 72% reduction in doses administered during April 2020 compared to 2019. Beyond these immediate impacts, primary care providers (PCPs) and other clinic members have reported ways in which the pandemic altered the landscape of vaccine conversations. , The rapid development and emergency authorization of COVID-19 vaccines, coupled with widespread public discourse and misinformation, contributed to heightened vaccine hesitancy that extended beyond COVID-19 vaccines to routine immunizations, including HPV vaccination. , Vaccine conversations have evolved for providers, as they have now found themselves engaging in complex conversations about vaccines in a changed primary care environment with more vaccine hesitancy. Particular concerns have been raised after the COVID-19 pandemic, where initial findings pointed toward changes in HPV vaccination uptake as the HPV vaccine was not being considered a priority, and providers were reporting more barriers to effective conversations about HPV vaccination. The traditional approaches to HPV vaccine conversations involving announcement strategies (i.e., the bundle approach, the Announcement Approach), developed and refined over the decade prior to the pandemic, may require adaptation to address evolving parental attitudes and concerns. , Now, providers must balance the need to address pandemic-related vaccine hesitancy while maintaining effective relationships with parents for HPV vaccination. Qualitative research conducted since the beginning of the pandemic has uncovered perspectives of PCPs and other clinic staff, regarding challenges to HPV vaccine conversations. “Right now with COVID, I would be amiss if I didn’t say HPV is probably not at the top of our list” was said by a clinic manager in a qualitative study in the Midwest US. Other qualitative studies with providers from the northeast US reported that, due to misinformation exacerbated by the pandemic, many families that used to vaccinate routinely were now refusing vaccines. Lastly, growing patterns of parental concerns across routine childhood vaccines were noted by providers interviewed from the southeast US. In light of the COVID-19 pandemic and the COVID-19 vaccine approval, researchers and practitioners have put forward efforts to understand changes in HPV vaccine conversations within their catchment areas. , , , This qualitative study involved an online survey and qualitative interview to understand how the COVID-19 pandemic affected how primary care team members (PCTMs) discuss HPV vaccination with their patients and explored the experiences of PCTMs when addressing HPV vaccination with their patients. 

Study population and setting This study was conducted in Pennsylvania from May 21 to July 3, 2024. PCTMs who engage in HPV vaccine conversations with patients, including pediatricians, family medicine physicians, medical residents or fellows, nurse practitioners, nursing staff (i.e., registered nurse, licensed practical nurse, licensed vocational nurse), medical assistants, and physician assistants were approached for the study. Participants were eligible if they (1) offered vaccination services to minors between 9 and 17 y old at any given point during the COVID-19 pandemic (defined as during or after March 2020) and (2) could read and write in English or Spanish (by self-report). Using convenience sampling, PCTMs were identified from online lists of pediatric-serving institutions in Pennsylvania. Participants of an active randomized controlled trial focusing on improving HPV vaccine communication were also invited to participate. Recruitment e-mails were sent to invite eligible participants to participate in an online survey and a 30-minute Zoom interview. The e-mails included a study flyer and a link to the study’s informed consent form, screening questions, and the short survey (described below) which were collected with the Research Electronic Data Capture (REDCap) platform. To be considered a participant for this study, interested PCTMs had to complete both the survey and the virtual interview. Upon completion of all study activities, participants were provided a $50 e-gift card. Once 25 consented study participants completed all study activites, study recruitment was considered finalized. The protocol for this study was approved by the Pennsylvania State University Institutional Review Board on December 11, 2023 (Study #00023977). Online survey The purpose of the online survey was to collect demographic information of participants and have a preliminary overview of their experiences with HPV vaccine conversations using common literature-based items. The survey included eight items measuring constructs related to provider confidence recommending HPV vaccination and discussing HPV vaccine-related questions with parents (i.e., diseases prevented through vaccination, safety or side effects, age of initiation), and perspectives on whether the COVID-19 pandemic or COVID-19 vaccine approval affected vaccination acceptance. Items were assessed using Likert-scale responses ranging from ‘strongly disagree’ to ‘strongly agree’ or ‘not confident at all’ to ‘completely confident.’ 21 Survey responses were collected using REDCap. Interview guide A semi-structured interview guide was developed by authors from diverse backgrounds related to the study (primary care practice, nursing, qualitative and mixed methods research, and vaccine communication). The interview guide was grounded in the Theory of Planned Behavior (TPB) and the Increasing Vaccination Model (IVM) frameworks. , Constructs of both frameworks have been previously used to examine vaccination behaviors and conversations, including HPV vaccination. Interview questions explored the constructs of attitudes, social norms, and perceived behavioral control from the TPB, and the constructs of social processes and practical issues from the IVM. The constructs of attitudes and perceived behavioral control from the TPB informed the exploration of PCTMs’ perspectives regarding how parents responded to HPV vaccine conversations before and throughout the pandemic. On the other hand, the TPB construct of social norms provided a space for PCTMs to delve into their beliefs about how the COVID-19 pandemic impacted HPV vaccine uptake and hesitancy. Regarding the IVM constructs of social processes and practical issues, these helped inform usual approaches to have HPV vaccine conversations and the identification of changes in these conversations since the pandemic. All interviews were conducted by JYLO, a doctoral student who has experience with qualitative methods, using the questions in . On average, the interviews lasted approximately 29:06 minutes (range: 13:45–48:50 minutes). Interviews were audio recorded and transcribed verbatim. Qualitative analysis An ontological assumption guided the data analysis as it assumes that every participant’s reality is subjective to preconceived notions, behaviors, and knowledge. In this case, the study team assumed that the experiences of the COVID-19 pandemic and the COVID-19 vaccine approval were dependent on characteristics true to the individual rather than on overarching beliefs. A descriptive phenomenological approach was deployed for the inductive thematic analysis, as the goal was to understand the realities of the pandemic on the participants’ experiences within known constructs related to HPV vaccine communication. Transcripts were analyzed using MAXQDA24, a qualitative software. A preliminary codebook was developed following the constructs from the TPB and the IVM (deductive construction). Additional codes were informed by common responses found in the interviews (inductive coding). All data was coded by two doctoral students (JYLO and JG) independently. Upon completion of coding, Cohen’s kappa statistic was used to obtain a score of interrater realiability and identify coding discrepancies to be reviewed by JYLO and JG. The initial kappa was 0.64, and all coding discrepancies were resolved through coder discussions to achieve a final kappa of 1. Coding discrepancies were solved through detailed review of participant responses involving both coders and the study team and informed by available HPV vaccine communication literature on the topic. , Coding reports were reviewed by an experienced qualitative researcher and a vaccine communication researcher (LJV and WAC, respectively). The manuscript follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist ( ). 

This study was conducted in Pennsylvania from May 21 to July 3, 2024. PCTMs who engage in HPV vaccine conversations with patients, including pediatricians, family medicine physicians, medical residents or fellows, nurse practitioners, nursing staff (i.e., registered nurse, licensed practical nurse, licensed vocational nurse), medical assistants, and physician assistants were approached for the study. Participants were eligible if they (1) offered vaccination services to minors between 9 and 17 y old at any given point during the COVID-19 pandemic (defined as during or after March 2020) and (2) could read and write in English or Spanish (by self-report). Using convenience sampling, PCTMs were identified from online lists of pediatric-serving institutions in Pennsylvania. Participants of an active randomized controlled trial focusing on improving HPV vaccine communication were also invited to participate. Recruitment e-mails were sent to invite eligible participants to participate in an online survey and a 30-minute Zoom interview. The e-mails included a study flyer and a link to the study’s informed consent form, screening questions, and the short survey (described below) which were collected with the Research Electronic Data Capture (REDCap) platform. To be considered a participant for this study, interested PCTMs had to complete both the survey and the virtual interview. Upon completion of all study activities, participants were provided a $50 e-gift card. Once 25 consented study participants completed all study activites, study recruitment was considered finalized. The protocol for this study was approved by the Pennsylvania State University Institutional Review Board on December 11, 2023 (Study #00023977). 

The purpose of the online survey was to collect demographic information of participants and have a preliminary overview of their experiences with HPV vaccine conversations using common literature-based items. The survey included eight items measuring constructs related to provider confidence recommending HPV vaccination and discussing HPV vaccine-related questions with parents (i.e., diseases prevented through vaccination, safety or side effects, age of initiation), and perspectives on whether the COVID-19 pandemic or COVID-19 vaccine approval affected vaccination acceptance. Items were assessed using Likert-scale responses ranging from ‘strongly disagree’ to ‘strongly agree’ or ‘not confident at all’ to ‘completely confident.’ 21 Survey responses were collected using REDCap. 

A semi-structured interview guide was developed by authors from diverse backgrounds related to the study (primary care practice, nursing, qualitative and mixed methods research, and vaccine communication). The interview guide was grounded in the Theory of Planned Behavior (TPB) and the Increasing Vaccination Model (IVM) frameworks. , Constructs of both frameworks have been previously used to examine vaccination behaviors and conversations, including HPV vaccination. Interview questions explored the constructs of attitudes, social norms, and perceived behavioral control from the TPB, and the constructs of social processes and practical issues from the IVM. The constructs of attitudes and perceived behavioral control from the TPB informed the exploration of PCTMs’ perspectives regarding how parents responded to HPV vaccine conversations before and throughout the pandemic. On the other hand, the TPB construct of social norms provided a space for PCTMs to delve into their beliefs about how the COVID-19 pandemic impacted HPV vaccine uptake and hesitancy. Regarding the IVM constructs of social processes and practical issues, these helped inform usual approaches to have HPV vaccine conversations and the identification of changes in these conversations since the pandemic. All interviews were conducted by JYLO, a doctoral student who has experience with qualitative methods, using the questions in . On average, the interviews lasted approximately 29:06 minutes (range: 13:45–48:50 minutes). Interviews were audio recorded and transcribed verbatim. 

An ontological assumption guided the data analysis as it assumes that every participant’s reality is subjective to preconceived notions, behaviors, and knowledge. In this case, the study team assumed that the experiences of the COVID-19 pandemic and the COVID-19 vaccine approval were dependent on characteristics true to the individual rather than on overarching beliefs. A descriptive phenomenological approach was deployed for the inductive thematic analysis, as the goal was to understand the realities of the pandemic on the participants’ experiences within known constructs related to HPV vaccine communication. Transcripts were analyzed using MAXQDA24, a qualitative software. A preliminary codebook was developed following the constructs from the TPB and the IVM (deductive construction). Additional codes were informed by common responses found in the interviews (inductive coding). All data was coded by two doctoral students (JYLO and JG) independently. Upon completion of coding, Cohen’s kappa statistic was used to obtain a score of interrater realiability and identify coding discrepancies to be reviewed by JYLO and JG. The initial kappa was 0.64, and all coding discrepancies were resolved through coder discussions to achieve a final kappa of 1. Coding discrepancies were solved through detailed review of participant responses involving both coders and the study team and informed by available HPV vaccine communication literature on the topic. , Coding reports were reviewed by an experienced qualitative researcher and a vaccine communication researcher (LJV and WAC, respectively). The manuscript follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist ( ). 

Participant characteristics are presented in . Most participants (80%) were female. Fifteen participants (60%) were physicians, out of which 11 were pediatricians and four were family medicine physicians. Seventeen participants (68%) identified as non-Hispanic White, with the rest indicating that they were Asian, Hispanic or Latino, or other. Almost half (46%) of the sample had 20 y of experience or more. Participants came from nine counties across regions in Pennsylvania (data not shown). Fifty-four percent of participants reported initiating HPV vaccine recommendations at 9–10 y old. When PCTMs were asked if they perceive that parents think HPV vaccination is important for their children, 76% agreed or strongly agreed ( ). Almost all participants (96%) reported high confidence in providing a strong HPV vaccine recommendation and addressing parental questions and concerns. When inquiring about how confident they felt addressing questions or concerns about specific topics related to the HPV vaccine, the top two topics that PCTMs felt completely confident talking about were age of initiation (68%) and school entry requirement (60%). On the other hand, PCTMs were least confident in addressing religious beliefs (20%) and HPV vaccine development and approval (32%). Regarding the impact of the COVID-19 pandemic on HPV vaccine uptake, 56% agreed or strongly agreed that the pandemic made the process more difficult. In addition, one-third (36%) of participants agreed or strongly agreed that the development of the COVID-19 vaccine had increased parental hesitancy toward the HPV vaccine. Interview findings Six themes were identified. Examples of participant quotes have been included by theme alongside participants’ roles, race and ethnicity, years of experience (Y/E), and participant ID. Theme 1: PCTMs are met with a range of reactions from parents during conversations about the HPV vaccine Upon inquiring about parental attitudes once the HPV vaccine is recommended for their children, participants reported that parents showed a range of reactions from acceptance to expressing questions or doubts to complete objection. Per PCTMs, parents that accept the HPV vaccine are either welcoming from the beginning or they go with their provider’s recommendation as to what the child is due for as part of their care. Most patients are all for it, meaning parents. Other parents will give a blank stare and they’re like, “Okay, if that’s what they’re due for.” -Medical Assistant, Non-Hispanic White, 20+ Y/E, P18 Other parents react by asking additional questions about the HPV vaccine to make sure that they understand what it is prior to making a decision. And then it goes into the whole realm of, “Well, I don’t think my child needs this yet,” or, “I don’t think it’s necessary,” or maybe, “Is it required for school? We can just hold off.” -Family Medicine Physician, Asian, <5 Y/E, P21 Among PCTMs that reported parental refusal of the HPV vaccine, they noted heightened hesitancy after the pandemic, minority populations showing “more hesitancy,” and parents who refuse the HPV vaccine specifically. I did see some more pushback for the vaccination and more hesitancy in African American communities, Black communities. And before the pandemic, in the area where I used to see patients, there was a lot of pushback and a lot of myth in regards to HPV vaccination that these families expressed to me, which was a high level of concern right before the pandemic started. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 Theme 2: Since the COVID-19 pandemic, disruptions in health-care visits and heightened parental concerns have impeded vaccine delivery and conversations When discussing the impact of the COVID-19 pandemic on HPV vaccination, PCTMs mentioned that cessation of in-person visits during the pandemic led patients to fall behind on their vaccination schedules, leading to delays that required PCTMs to work on getting these patients back on schedule. The problem being during COVID was people were not coming in for their well visits. So when they didn’t come in for their well visits, because they were afraid to go especially into a doctor’s office at that point, you weren’t getting the amount of people there that should have been vaccinated at that time. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P9 PCTMs also noted heightened parental concerns regarding the components, long-term biological impact, and effectiveness of vaccines. PCTMs report that these concerns seem to nudge parents toward more hesitancy, bringing up more questions about vaccine administration and safety, and refusal of routine childhood vaccines than they had experienced pre-pandemic. What has changed is the number of parents that are skeptical of all of our vaccines. So not just HPV, but now there are families that used to vaccinate normally and on schedule, that they’re cautious about the regular ones that have been around for decades, and about ingredients, or about contaminants, or about impact on neuro-development, that there’s a new level of concern that wasn’t there before. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 PCTMs explained that some parents did not “agree” with the COVID-19 vaccine and they would mention this aversion within their conversations of wanting to delay or not wanting to get other vaccines. They mention the pandemic. They’ll say about the COVID vaccine and they don’t agree with it, so therefore they don’t want to do other vaccines. They want more information. They’re going to wait. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P3 One PCTM explained how parents were concerned that they would try to ‘sneak in’ the COVID vaccine if the child was getting other vaccines. And then, once the pandemic started to slow down and then we had COVID vaccine, I had a lot more resistance about getting just the regular childhood vaccines because parents really thought that I was going to try and sneak a COVID vaccine in in addition to their regular childhood vaccines. And so I had a lot more questions and a lot more refusals. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Other PCTMs mentioned how parents who previously did not exhibit hesitation now mention concerns of side effects and vaccine ingredients. PCTMs described less overall trust in vaccines, which has led to general vaccine hesitancy. This has also co-occurred with an extended vaccine schedule that now includes an additional vaccine (referring to the COVID-19 vaccine) in their immunization conversations. Notably, one PCTM indicated that the COVID-19 pandemic may have shifted some parents to be more aware of the importance of vaccination by understanding the risks of infectious diseases, leading them to want all vaccines upon presentation rather than spacing them out. I think the COVID pandemic kind of pushed people toward, “Oh, this could be something bad,” so it’s like maybe they’re more willing to get it all at once, because we vaccinate at 11. So, at 11, they normally get the tetanus, they normally get Menactra, and then they normally get the HPV vaccine. So it’s like …before, it was kind of like, “Well, let’s wait a little bit for one, and space them out,” but now, it’s just like, “Let’s get it done, because it protects my child against something that we know they can be protected against.” -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 Theme 3: Many PCTMs reported noticing clear changes in the rate of vaccine acceptance since the pandemic PCTMs reported changes related to HPV vaccination in their clinics, with some PCTMs (n = 8) reporting an increase in uptake and others (n = 7) reporting a decrease. Among those reporting an increase in vaccination, some mentioned the advantages of starting the conversation about the vaccine at age 9, compared to previous approaches starting at age 11. For PCTMs, starting the HPV vaccine conversation at age 9 allows them to have more time to talk to parents about its importance and safety for their children. I actually think that the uptake is higher now in the last year, because we’re talking about it earlier. And if they don’t get it at nine, we’re revisiting it at 10. And then they’ve heard about it several times, and are ready to vaccinate, or have thought about it. So I think that complicates what happened during the pandemic discussion, really. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 On the other hand, those reporting a decrease in the uptake of the HPV vaccine mentioned the impact of the pandemic as a driving factor and parental concern that the COVID-19 vaccine was mixed in within the HPV vaccine dose. I will say it is more of a decrease. They are definitely decreasing (the number of parents accepting the HPV vaccine for their children) because of the fact that they are worried about having their children getting the COVID vaccine and they’re always curious, ‘oh, it’s not mixed in, it’s not boostered with it.’ They’re always hesitant because they don’t want that vaccine, so they always are questioning. ‘It’s not a combination or anything like that?’ But once we explain that it is just the vaccine, it has nothing to do with COVID, they seem to be more okay with it then. -Medical Assistant, Non-Hispanic White, 10–14 Y/E, P2 When asked about changes in HPV vaccine hesitancy, 11 PCTMs reported observing an increase, 6 reported no change, and 7 reported a decrease. One of the suspected reasons behind observed increases was the exposure to inaccurate information regarding the COVID-19 vaccine, which seemed to prompt parents to ask more questions about other vaccines, including the HPV. It wasn’t just the HPV, it was like people were so freaked out by the false information about the COVID vaccine that they didn’t want their child to have any vaccines. But the HPV, if a parent… They were just asking more questions than they did before. -Medical Assistant, Multiracial, 5–9 Y/E, P13 Other PCTMs noted that the observed increase in hesitancy occurred mainly after the approval of the COVID-19 vaccine boosters and was more marked among parents of younger children that have not received many vaccines. I think the hesitancy has been more with the younger kids and the new parents than necessarily an increase with those who are already established in their immunization system. -Pediatrician, Non-Hispanic White, 20+ Y/E, P25 On the other hand, time passing since the peak of the pandemic has helped decrease hesitancy levels among parents. One PCTM mentioned that the decrease in hesitancy toward the HPV vaccine may be because it has been approved for ‘many years,’ a fact that was mentioned by another PCTM as also helping HPV vaccination uptake increase. Related to the pandemic, a PCTM suggested that the more time passes since the beginning of the pandemic, parental hesitancy seems to decrease. I would say you still got that hesitancy in some parents, but I think it has lessened, just for the fact, like I said before, it’s (the HPV vaccine) been out a while, so you know you have that push behind it, like saying, “It’s been tested, it’s been proven,” you know what I mean? -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 Theme 4: The reasons parents decline the HPV vaccine have not substantially changed as a result of the pandemic Sixteen PCTMs reported little to no change in the reasons parents do not accept HPV vaccination for their children. They reported that parents still mention that the HPV vaccine is ‘too new,’ they question the need of the vaccine for their child based on their age, the fact that their children are not sexually active, and concerns about the vaccine causing fertility issues. I don’t think they’ve changed too much. They’re still giving me the same reasons that they choose not to vaccinate for HPV. They’re still telling me the vaccine is too new. They’re still telling me that it’s not a necessary vaccine at this age. They’re still telling me that it’s a vaccine that they don’t think is appropriate for their age group. They’re still telling me the same reasons. It just seems like they’re telling me more often. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 An emerging reason that PCTMs have observed from parents to decline the HPV vaccine is their surprise when the vaccine has been offered at age 9. Prior to the pandemic, we were routinely giving the HPV vaccine starting at age 11. Since the pandemic, we have moved up the timing, the first time we introduced the vaccine to families, to age 9. So that has been a change. And so, there are some people who question why are we giving it at 9, particularly those who had prior children who got it at 11 or their own experience of getting it at age 11. So they’re questioning why the change in age. -Pediatrician, Non-Hispanic White, 20+ Y/E, P19 Theme 5: PCTMs highlight that interpersonal relationships and sharing scientific information in layperson terms are key aspects of vaccine conversations PCTMs discussed recommendation approaches to address HPV vaccine conversations with hesitant parents including personal connection, presentation of scientific information, and tailored messaging focusing on topics ranging from cancer prevention to vaccination series. Through personal connection, PCTMs expressed that they are able to resonate with parental desire to make sure that they are protecting their child’s health. [As if speaking to parents and child at a visit] I’m a mom, two boys, and by 11, they both got their HPV shots; they’re fully immunized. And I love my children and I’m going to tell you that I would never give something to my kids that is not good or is harmful to them. So my own children are vaccinated against HPV and I wish women of my generation, because we were older when the vaccine came, I wish that we had that opportunity. So now your child has that opportunity and if you want to think about it, let me know. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 Providing scientific information verbally or through printed materials to highlight the importance of the HPV vaccine was also brought up as a way that PCTMs are able to explore the topic with parents. You hear the same conversations over and over, and so when I have parents who try to tell me that it’s too new, I generally have a conversation with them about the fact that the [HPV vaccine] has been out for longer than the [smartphone] that they have in their hands, and that usually will calm some of their fears. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Some PCTMs use an approach of stating that the HPV vaccine is ‘due’ rather than ‘suggesting’ the HPV vaccine. Additionally, seeking to truly understand the origins of parental concerns allows PCTMs to identify specific topics in which they may explore in more depth. So, I think I have… and this has been my own experience as well, that I find it’s best to start with, “Help me understand why you’re saying what you’re saying.” And to just have a detailed understanding of what their priorities are, what’s driving their decision making, and maybe there’s a legitimate thing there. So, I think, starting with some humility and saying that, “Well, why are you saying this? And what makes you feel that way?” And maybe there is a reasonable explanation for this. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 Other common topics discussed with hesitant parents include the starting age-based series of the HPV vaccine, the difference between school requirements and recommended vaccines, and talking about the cancer prevention capacity of the vaccine. Addressing HPV vaccine conversations with hesitant parents comes with other limitations, such as not being able to discuss the topic thoroughly depending on the provider type, provider burnout, and confronting known concerns such as the male versus female conundrum for the HPV vaccine. Theme 6: PCTM burnout and COVID-19 vaccine aversion are impacting vaccine conversations PCTMs reported experiencing high levels of burnout to the point of feeling that they cannot push further into these conversations. I do feel like there was a period of time people were tired, just so tired of arguing. I definitely felt like you got to a point in the practice where the resident would come back and be like, “This parent’s refusing vaccines.” And I’d be like, “Okay, just fine. I’m done. I can’t convince anybody else to do any more stuff. I am just totally worn out from it.” -Pediatrician, Asian, 15–19 Y/E, P22 Further, PCTMs are reporting that parents seem to think that they are not looking out for their well-being by recommending vaccines, PCTMs need to give parents more information than before, and vaccine conversations can be more challenging due to parental concerns for the COVID-19 vaccine. These beliefs and perceptions on behalf of parents have increased tensions during vaccine conversations, with PCTMs now having to spend more time convincing parents that they are looking out for the child’s health. I would say that I have had to give a lot more detail. I personally have had to empower myself and to educate myself a little bit more and review these disease processes that we’re trying to prevent, especially HPV, because not only do I need to understand it and be able to pretty much answer any question, but I have to also be able to speak to my patients and their families at the level that they understand. -Family Medicine Physician, Asian, <5 Y/E, P17 However, when these conversations are frequent and prolonged by parents focusing on not wanting certain vaccines for their children, PCTMs feel that they have ‘less gas in the tank’ to move forward with these conversations. I think the change has been that I have less gas in the tank to wade into these conversations, because I’ve been ground down day after day, hearing people tell me why they don’t want COVID and flu vaccines. There’s just a resignation, you know? And unfortunately that bleeds over into these conversations about HPV, because it very much pushes the same emotional button for me, and you know. Being the point of the spear at the front line of healthcare as part of trying to implement these recommendations has been exhausting. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 

Six themes were identified. Examples of participant quotes have been included by theme alongside participants’ roles, race and ethnicity, years of experience (Y/E), and participant ID. Theme 1: PCTMs are met with a range of reactions from parents during conversations about the HPV vaccine Upon inquiring about parental attitudes once the HPV vaccine is recommended for their children, participants reported that parents showed a range of reactions from acceptance to expressing questions or doubts to complete objection. Per PCTMs, parents that accept the HPV vaccine are either welcoming from the beginning or they go with their provider’s recommendation as to what the child is due for as part of their care. Most patients are all for it, meaning parents. Other parents will give a blank stare and they’re like, “Okay, if that’s what they’re due for.” -Medical Assistant, Non-Hispanic White, 20+ Y/E, P18 Other parents react by asking additional questions about the HPV vaccine to make sure that they understand what it is prior to making a decision. And then it goes into the whole realm of, “Well, I don’t think my child needs this yet,” or, “I don’t think it’s necessary,” or maybe, “Is it required for school? We can just hold off.” -Family Medicine Physician, Asian, <5 Y/E, P21 Among PCTMs that reported parental refusal of the HPV vaccine, they noted heightened hesitancy after the pandemic, minority populations showing “more hesitancy,” and parents who refuse the HPV vaccine specifically. I did see some more pushback for the vaccination and more hesitancy in African American communities, Black communities. And before the pandemic, in the area where I used to see patients, there was a lot of pushback and a lot of myth in regards to HPV vaccination that these families expressed to me, which was a high level of concern right before the pandemic started. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 Theme 2: Since the COVID-19 pandemic, disruptions in health-care visits and heightened parental concerns have impeded vaccine delivery and conversations When discussing the impact of the COVID-19 pandemic on HPV vaccination, PCTMs mentioned that cessation of in-person visits during the pandemic led patients to fall behind on their vaccination schedules, leading to delays that required PCTMs to work on getting these patients back on schedule. The problem being during COVID was people were not coming in for their well visits. So when they didn’t come in for their well visits, because they were afraid to go especially into a doctor’s office at that point, you weren’t getting the amount of people there that should have been vaccinated at that time. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P9 PCTMs also noted heightened parental concerns regarding the components, long-term biological impact, and effectiveness of vaccines. PCTMs report that these concerns seem to nudge parents toward more hesitancy, bringing up more questions about vaccine administration and safety, and refusal of routine childhood vaccines than they had experienced pre-pandemic. What has changed is the number of parents that are skeptical of all of our vaccines. So not just HPV, but now there are families that used to vaccinate normally and on schedule, that they’re cautious about the regular ones that have been around for decades, and about ingredients, or about contaminants, or about impact on neuro-development, that there’s a new level of concern that wasn’t there before. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 PCTMs explained that some parents did not “agree” with the COVID-19 vaccine and they would mention this aversion within their conversations of wanting to delay or not wanting to get other vaccines. They mention the pandemic. They’ll say about the COVID vaccine and they don’t agree with it, so therefore they don’t want to do other vaccines. They want more information. They’re going to wait. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P3 One PCTM explained how parents were concerned that they would try to ‘sneak in’ the COVID vaccine if the child was getting other vaccines. And then, once the pandemic started to slow down and then we had COVID vaccine, I had a lot more resistance about getting just the regular childhood vaccines because parents really thought that I was going to try and sneak a COVID vaccine in in addition to their regular childhood vaccines. And so I had a lot more questions and a lot more refusals. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Other PCTMs mentioned how parents who previously did not exhibit hesitation now mention concerns of side effects and vaccine ingredients. PCTMs described less overall trust in vaccines, which has led to general vaccine hesitancy. This has also co-occurred with an extended vaccine schedule that now includes an additional vaccine (referring to the COVID-19 vaccine) in their immunization conversations. Notably, one PCTM indicated that the COVID-19 pandemic may have shifted some parents to be more aware of the importance of vaccination by understanding the risks of infectious diseases, leading them to want all vaccines upon presentation rather than spacing them out. I think the COVID pandemic kind of pushed people toward, “Oh, this could be something bad,” so it’s like maybe they’re more willing to get it all at once, because we vaccinate at 11. So, at 11, they normally get the tetanus, they normally get Menactra, and then they normally get the HPV vaccine. So it’s like …before, it was kind of like, “Well, let’s wait a little bit for one, and space them out,” but now, it’s just like, “Let’s get it done, because it protects my child against something that we know they can be protected against.” -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 Theme 3: Many PCTMs reported noticing clear changes in the rate of vaccine acceptance since the pandemic PCTMs reported changes related to HPV vaccination in their clinics, with some PCTMs (n = 8) reporting an increase in uptake and others (n = 7) reporting a decrease. Among those reporting an increase in vaccination, some mentioned the advantages of starting the conversation about the vaccine at age 9, compared to previous approaches starting at age 11. For PCTMs, starting the HPV vaccine conversation at age 9 allows them to have more time to talk to parents about its importance and safety for their children. I actually think that the uptake is higher now in the last year, because we’re talking about it earlier. And if they don’t get it at nine, we’re revisiting it at 10. And then they’ve heard about it several times, and are ready to vaccinate, or have thought about it. So I think that complicates what happened during the pandemic discussion, really. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 On the other hand, those reporting a decrease in the uptake of the HPV vaccine mentioned the impact of the pandemic as a driving factor and parental concern that the COVID-19 vaccine was mixed in within the HPV vaccine dose. I will say it is more of a decrease. They are definitely decreasing (the number of parents accepting the HPV vaccine for their children) because of the fact that they are worried about having their children getting the COVID vaccine and they’re always curious, ‘oh, it’s not mixed in, it’s not boostered with it.’ They’re always hesitant because they don’t want that vaccine, so they always are questioning. ‘It’s not a combination or anything like that?’ But once we explain that it is just the vaccine, it has nothing to do with COVID, they seem to be more okay with it then. -Medical Assistant, Non-Hispanic White, 10–14 Y/E, P2 When asked about changes in HPV vaccine hesitancy, 11 PCTMs reported observing an increase, 6 reported no change, and 7 reported a decrease. One of the suspected reasons behind observed increases was the exposure to inaccurate information regarding the COVID-19 vaccine, which seemed to prompt parents to ask more questions about other vaccines, including the HPV. It wasn’t just the HPV, it was like people were so freaked out by the false information about the COVID vaccine that they didn’t want their child to have any vaccines. But the HPV, if a parent… They were just asking more questions than they did before. -Medical Assistant, Multiracial, 5–9 Y/E, P13 Other PCTMs noted that the observed increase in hesitancy occurred mainly after the approval of the COVID-19 vaccine boosters and was more marked among parents of younger children that have not received many vaccines. I think the hesitancy has been more with the younger kids and the new parents than necessarily an increase with those who are already established in their immunization system. -Pediatrician, Non-Hispanic White, 20+ Y/E, P25 On the other hand, time passing since the peak of the pandemic has helped decrease hesitancy levels among parents. One PCTM mentioned that the decrease in hesitancy toward the HPV vaccine may be because it has been approved for ‘many years,’ a fact that was mentioned by another PCTM as also helping HPV vaccination uptake increase. Related to the pandemic, a PCTM suggested that the more time passes since the beginning of the pandemic, parental hesitancy seems to decrease. I would say you still got that hesitancy in some parents, but I think it has lessened, just for the fact, like I said before, it’s (the HPV vaccine) been out a while, so you know you have that push behind it, like saying, “It’s been tested, it’s been proven,” you know what I mean? -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 Theme 4: The reasons parents decline the HPV vaccine have not substantially changed as a result of the pandemic Sixteen PCTMs reported little to no change in the reasons parents do not accept HPV vaccination for their children. They reported that parents still mention that the HPV vaccine is ‘too new,’ they question the need of the vaccine for their child based on their age, the fact that their children are not sexually active, and concerns about the vaccine causing fertility issues. I don’t think they’ve changed too much. They’re still giving me the same reasons that they choose not to vaccinate for HPV. They’re still telling me the vaccine is too new. They’re still telling me that it’s not a necessary vaccine at this age. They’re still telling me that it’s a vaccine that they don’t think is appropriate for their age group. They’re still telling me the same reasons. It just seems like they’re telling me more often. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 An emerging reason that PCTMs have observed from parents to decline the HPV vaccine is their surprise when the vaccine has been offered at age 9. Prior to the pandemic, we were routinely giving the HPV vaccine starting at age 11. Since the pandemic, we have moved up the timing, the first time we introduced the vaccine to families, to age 9. So that has been a change. And so, there are some people who question why are we giving it at 9, particularly those who had prior children who got it at 11 or their own experience of getting it at age 11. So they’re questioning why the change in age. -Pediatrician, Non-Hispanic White, 20+ Y/E, P19 Theme 5: PCTMs highlight that interpersonal relationships and sharing scientific information in layperson terms are key aspects of vaccine conversations PCTMs discussed recommendation approaches to address HPV vaccine conversations with hesitant parents including personal connection, presentation of scientific information, and tailored messaging focusing on topics ranging from cancer prevention to vaccination series. Through personal connection, PCTMs expressed that they are able to resonate with parental desire to make sure that they are protecting their child’s health. [As if speaking to parents and child at a visit] I’m a mom, two boys, and by 11, they both got their HPV shots; they’re fully immunized. And I love my children and I’m going to tell you that I would never give something to my kids that is not good or is harmful to them. So my own children are vaccinated against HPV and I wish women of my generation, because we were older when the vaccine came, I wish that we had that opportunity. So now your child has that opportunity and if you want to think about it, let me know. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 Providing scientific information verbally or through printed materials to highlight the importance of the HPV vaccine was also brought up as a way that PCTMs are able to explore the topic with parents. You hear the same conversations over and over, and so when I have parents who try to tell me that it’s too new, I generally have a conversation with them about the fact that the [HPV vaccine] has been out for longer than the [smartphone] that they have in their hands, and that usually will calm some of their fears. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Some PCTMs use an approach of stating that the HPV vaccine is ‘due’ rather than ‘suggesting’ the HPV vaccine. Additionally, seeking to truly understand the origins of parental concerns allows PCTMs to identify specific topics in which they may explore in more depth. So, I think I have… and this has been my own experience as well, that I find it’s best to start with, “Help me understand why you’re saying what you’re saying.” And to just have a detailed understanding of what their priorities are, what’s driving their decision making, and maybe there’s a legitimate thing there. So, I think, starting with some humility and saying that, “Well, why are you saying this? And what makes you feel that way?” And maybe there is a reasonable explanation for this. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 Other common topics discussed with hesitant parents include the starting age-based series of the HPV vaccine, the difference between school requirements and recommended vaccines, and talking about the cancer prevention capacity of the vaccine. Addressing HPV vaccine conversations with hesitant parents comes with other limitations, such as not being able to discuss the topic thoroughly depending on the provider type, provider burnout, and confronting known concerns such as the male versus female conundrum for the HPV vaccine. Theme 6: PCTM burnout and COVID-19 vaccine aversion are impacting vaccine conversations PCTMs reported experiencing high levels of burnout to the point of feeling that they cannot push further into these conversations. I do feel like there was a period of time people were tired, just so tired of arguing. I definitely felt like you got to a point in the practice where the resident would come back and be like, “This parent’s refusing vaccines.” And I’d be like, “Okay, just fine. I’m done. I can’t convince anybody else to do any more stuff. I am just totally worn out from it.” -Pediatrician, Asian, 15–19 Y/E, P22 Further, PCTMs are reporting that parents seem to think that they are not looking out for their well-being by recommending vaccines, PCTMs need to give parents more information than before, and vaccine conversations can be more challenging due to parental concerns for the COVID-19 vaccine. These beliefs and perceptions on behalf of parents have increased tensions during vaccine conversations, with PCTMs now having to spend more time convincing parents that they are looking out for the child’s health. I would say that I have had to give a lot more detail. I personally have had to empower myself and to educate myself a little bit more and review these disease processes that we’re trying to prevent, especially HPV, because not only do I need to understand it and be able to pretty much answer any question, but I have to also be able to speak to my patients and their families at the level that they understand. -Family Medicine Physician, Asian, <5 Y/E, P17 However, when these conversations are frequent and prolonged by parents focusing on not wanting certain vaccines for their children, PCTMs feel that they have ‘less gas in the tank’ to move forward with these conversations. I think the change has been that I have less gas in the tank to wade into these conversations, because I’ve been ground down day after day, hearing people tell me why they don’t want COVID and flu vaccines. There’s just a resignation, you know? And unfortunately that bleeds over into these conversations about HPV, because it very much pushes the same emotional button for me, and you know. Being the point of the spear at the front line of healthcare as part of trying to implement these recommendations has been exhausting. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 

Upon inquiring about parental attitudes once the HPV vaccine is recommended for their children, participants reported that parents showed a range of reactions from acceptance to expressing questions or doubts to complete objection. Per PCTMs, parents that accept the HPV vaccine are either welcoming from the beginning or they go with their provider’s recommendation as to what the child is due for as part of their care. Most patients are all for it, meaning parents. Other parents will give a blank stare and they’re like, “Okay, if that’s what they’re due for.” -Medical Assistant, Non-Hispanic White, 20+ Y/E, P18 Other parents react by asking additional questions about the HPV vaccine to make sure that they understand what it is prior to making a decision. And then it goes into the whole realm of, “Well, I don’t think my child needs this yet,” or, “I don’t think it’s necessary,” or maybe, “Is it required for school? We can just hold off.” -Family Medicine Physician, Asian, <5 Y/E, P21 Among PCTMs that reported parental refusal of the HPV vaccine, they noted heightened hesitancy after the pandemic, minority populations showing “more hesitancy,” and parents who refuse the HPV vaccine specifically. I did see some more pushback for the vaccination and more hesitancy in African American communities, Black communities. And before the pandemic, in the area where I used to see patients, there was a lot of pushback and a lot of myth in regards to HPV vaccination that these families expressed to me, which was a high level of concern right before the pandemic started. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 

When discussing the impact of the COVID-19 pandemic on HPV vaccination, PCTMs mentioned that cessation of in-person visits during the pandemic led patients to fall behind on their vaccination schedules, leading to delays that required PCTMs to work on getting these patients back on schedule. The problem being during COVID was people were not coming in for their well visits. So when they didn’t come in for their well visits, because they were afraid to go especially into a doctor’s office at that point, you weren’t getting the amount of people there that should have been vaccinated at that time. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P9 PCTMs also noted heightened parental concerns regarding the components, long-term biological impact, and effectiveness of vaccines. PCTMs report that these concerns seem to nudge parents toward more hesitancy, bringing up more questions about vaccine administration and safety, and refusal of routine childhood vaccines than they had experienced pre-pandemic. What has changed is the number of parents that are skeptical of all of our vaccines. So not just HPV, but now there are families that used to vaccinate normally and on schedule, that they’re cautious about the regular ones that have been around for decades, and about ingredients, or about contaminants, or about impact on neuro-development, that there’s a new level of concern that wasn’t there before. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 PCTMs explained that some parents did not “agree” with the COVID-19 vaccine and they would mention this aversion within their conversations of wanting to delay or not wanting to get other vaccines. They mention the pandemic. They’ll say about the COVID vaccine and they don’t agree with it, so therefore they don’t want to do other vaccines. They want more information. They’re going to wait. -Nursing Staff, Non-Hispanic White, 20+ Y/E, P3 One PCTM explained how parents were concerned that they would try to ‘sneak in’ the COVID vaccine if the child was getting other vaccines. And then, once the pandemic started to slow down and then we had COVID vaccine, I had a lot more resistance about getting just the regular childhood vaccines because parents really thought that I was going to try and sneak a COVID vaccine in in addition to their regular childhood vaccines. And so I had a lot more questions and a lot more refusals. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Other PCTMs mentioned how parents who previously did not exhibit hesitation now mention concerns of side effects and vaccine ingredients. PCTMs described less overall trust in vaccines, which has led to general vaccine hesitancy. This has also co-occurred with an extended vaccine schedule that now includes an additional vaccine (referring to the COVID-19 vaccine) in their immunization conversations. Notably, one PCTM indicated that the COVID-19 pandemic may have shifted some parents to be more aware of the importance of vaccination by understanding the risks of infectious diseases, leading them to want all vaccines upon presentation rather than spacing them out. I think the COVID pandemic kind of pushed people toward, “Oh, this could be something bad,” so it’s like maybe they’re more willing to get it all at once, because we vaccinate at 11. So, at 11, they normally get the tetanus, they normally get Menactra, and then they normally get the HPV vaccine. So it’s like …before, it was kind of like, “Well, let’s wait a little bit for one, and space them out,” but now, it’s just like, “Let’s get it done, because it protects my child against something that we know they can be protected against.” -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 

PCTMs reported changes related to HPV vaccination in their clinics, with some PCTMs (n = 8) reporting an increase in uptake and others (n = 7) reporting a decrease. Among those reporting an increase in vaccination, some mentioned the advantages of starting the conversation about the vaccine at age 9, compared to previous approaches starting at age 11. For PCTMs, starting the HPV vaccine conversation at age 9 allows them to have more time to talk to parents about its importance and safety for their children. I actually think that the uptake is higher now in the last year, because we’re talking about it earlier. And if they don’t get it at nine, we’re revisiting it at 10. And then they’ve heard about it several times, and are ready to vaccinate, or have thought about it. So I think that complicates what happened during the pandemic discussion, really. -Pediatrician, Non-Hispanic White, 15–19 Y/E, P24 On the other hand, those reporting a decrease in the uptake of the HPV vaccine mentioned the impact of the pandemic as a driving factor and parental concern that the COVID-19 vaccine was mixed in within the HPV vaccine dose. I will say it is more of a decrease. They are definitely decreasing (the number of parents accepting the HPV vaccine for their children) because of the fact that they are worried about having their children getting the COVID vaccine and they’re always curious, ‘oh, it’s not mixed in, it’s not boostered with it.’ They’re always hesitant because they don’t want that vaccine, so they always are questioning. ‘It’s not a combination or anything like that?’ But once we explain that it is just the vaccine, it has nothing to do with COVID, they seem to be more okay with it then. -Medical Assistant, Non-Hispanic White, 10–14 Y/E, P2 When asked about changes in HPV vaccine hesitancy, 11 PCTMs reported observing an increase, 6 reported no change, and 7 reported a decrease. One of the suspected reasons behind observed increases was the exposure to inaccurate information regarding the COVID-19 vaccine, which seemed to prompt parents to ask more questions about other vaccines, including the HPV. It wasn’t just the HPV, it was like people were so freaked out by the false information about the COVID vaccine that they didn’t want their child to have any vaccines. But the HPV, if a parent… They were just asking more questions than they did before. -Medical Assistant, Multiracial, 5–9 Y/E, P13 Other PCTMs noted that the observed increase in hesitancy occurred mainly after the approval of the COVID-19 vaccine boosters and was more marked among parents of younger children that have not received many vaccines. I think the hesitancy has been more with the younger kids and the new parents than necessarily an increase with those who are already established in their immunization system. -Pediatrician, Non-Hispanic White, 20+ Y/E, P25 On the other hand, time passing since the peak of the pandemic has helped decrease hesitancy levels among parents. One PCTM mentioned that the decrease in hesitancy toward the HPV vaccine may be because it has been approved for ‘many years,’ a fact that was mentioned by another PCTM as also helping HPV vaccination uptake increase. Related to the pandemic, a PCTM suggested that the more time passes since the beginning of the pandemic, parental hesitancy seems to decrease. I would say you still got that hesitancy in some parents, but I think it has lessened, just for the fact, like I said before, it’s (the HPV vaccine) been out a while, so you know you have that push behind it, like saying, “It’s been tested, it’s been proven,” you know what I mean? -Medical Assistant, Non-Hispanic White, 5–9 Y/E, P10 

Sixteen PCTMs reported little to no change in the reasons parents do not accept HPV vaccination for their children. They reported that parents still mention that the HPV vaccine is ‘too new,’ they question the need of the vaccine for their child based on their age, the fact that their children are not sexually active, and concerns about the vaccine causing fertility issues. I don’t think they’ve changed too much. They’re still giving me the same reasons that they choose not to vaccinate for HPV. They’re still telling me the vaccine is too new. They’re still telling me that it’s not a necessary vaccine at this age. They’re still telling me that it’s a vaccine that they don’t think is appropriate for their age group. They’re still telling me the same reasons. It just seems like they’re telling me more often. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 An emerging reason that PCTMs have observed from parents to decline the HPV vaccine is their surprise when the vaccine has been offered at age 9. Prior to the pandemic, we were routinely giving the HPV vaccine starting at age 11. Since the pandemic, we have moved up the timing, the first time we introduced the vaccine to families, to age 9. So that has been a change. And so, there are some people who question why are we giving it at 9, particularly those who had prior children who got it at 11 or their own experience of getting it at age 11. So they’re questioning why the change in age. -Pediatrician, Non-Hispanic White, 20+ Y/E, P19 

PCTMs discussed recommendation approaches to address HPV vaccine conversations with hesitant parents including personal connection, presentation of scientific information, and tailored messaging focusing on topics ranging from cancer prevention to vaccination series. Through personal connection, PCTMs expressed that they are able to resonate with parental desire to make sure that they are protecting their child’s health. [As if speaking to parents and child at a visit] I’m a mom, two boys, and by 11, they both got their HPV shots; they’re fully immunized. And I love my children and I’m going to tell you that I would never give something to my kids that is not good or is harmful to them. So my own children are vaccinated against HPV and I wish women of my generation, because we were older when the vaccine came, I wish that we had that opportunity. So now your child has that opportunity and if you want to think about it, let me know. -Pediatrician, Hispanic/Latino, 20+ Y/E, P15 Providing scientific information verbally or through printed materials to highlight the importance of the HPV vaccine was also brought up as a way that PCTMs are able to explore the topic with parents. You hear the same conversations over and over, and so when I have parents who try to tell me that it’s too new, I generally have a conversation with them about the fact that the [HPV vaccine] has been out for longer than the [smartphone] that they have in their hands, and that usually will calm some of their fears. -Pediatrician, Non-Hispanic White, 10–14 Y/E, P1 Some PCTMs use an approach of stating that the HPV vaccine is ‘due’ rather than ‘suggesting’ the HPV vaccine. Additionally, seeking to truly understand the origins of parental concerns allows PCTMs to identify specific topics in which they may explore in more depth. So, I think I have… and this has been my own experience as well, that I find it’s best to start with, “Help me understand why you’re saying what you’re saying.” And to just have a detailed understanding of what their priorities are, what’s driving their decision making, and maybe there’s a legitimate thing there. So, I think, starting with some humility and saying that, “Well, why are you saying this? And what makes you feel that way?” And maybe there is a reasonable explanation for this. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 Other common topics discussed with hesitant parents include the starting age-based series of the HPV vaccine, the difference between school requirements and recommended vaccines, and talking about the cancer prevention capacity of the vaccine. Addressing HPV vaccine conversations with hesitant parents comes with other limitations, such as not being able to discuss the topic thoroughly depending on the provider type, provider burnout, and confronting known concerns such as the male versus female conundrum for the HPV vaccine. 

PCTMs reported experiencing high levels of burnout to the point of feeling that they cannot push further into these conversations. I do feel like there was a period of time people were tired, just so tired of arguing. I definitely felt like you got to a point in the practice where the resident would come back and be like, “This parent’s refusing vaccines.” And I’d be like, “Okay, just fine. I’m done. I can’t convince anybody else to do any more stuff. I am just totally worn out from it.” -Pediatrician, Asian, 15–19 Y/E, P22 Further, PCTMs are reporting that parents seem to think that they are not looking out for their well-being by recommending vaccines, PCTMs need to give parents more information than before, and vaccine conversations can be more challenging due to parental concerns for the COVID-19 vaccine. These beliefs and perceptions on behalf of parents have increased tensions during vaccine conversations, with PCTMs now having to spend more time convincing parents that they are looking out for the child’s health. I would say that I have had to give a lot more detail. I personally have had to empower myself and to educate myself a little bit more and review these disease processes that we’re trying to prevent, especially HPV, because not only do I need to understand it and be able to pretty much answer any question, but I have to also be able to speak to my patients and their families at the level that they understand. -Family Medicine Physician, Asian, <5 Y/E, P17 However, when these conversations are frequent and prolonged by parents focusing on not wanting certain vaccines for their children, PCTMs feel that they have ‘less gas in the tank’ to move forward with these conversations. I think the change has been that I have less gas in the tank to wade into these conversations, because I’ve been ground down day after day, hearing people tell me why they don’t want COVID and flu vaccines. There’s just a resignation, you know? And unfortunately that bleeds over into these conversations about HPV, because it very much pushes the same emotional button for me, and you know. Being the point of the spear at the front line of healthcare as part of trying to implement these recommendations has been exhausting. -Family Medicine Physician, Non-Hispanic White, 20+ Y/E, P23 

The findings of this study provide insights into how the pandemic impacted HPV vaccine conversations between PCTMs and patients since the COVID-19 pandemic. Overall, study participants reported various parental reactions, heightened concerns about vaccines, changes in HPV vaccination uptake and hesitancy, minor changes in reasons to decline the HPV vaccine, the importance of interpersonal relationships, and the impact of PCTM burnout during HPV vaccine conversations. Overall, these findings align with interviews conducted early in the pandemic (August–November 2020), with providers highlighting the immediate impact of the COVID-19 pandemic on vaccine delivery and conversations due to well-visit interruptions. Similar to other US-based studies interviewing PCPs and other clinic staff that serve minors, participants in our study expressed how vaccine-related concerns seemed to increase since the pandemic, including concerns related to the HPV vaccine. , , The scope of these concerns ranged from unfamiliarity with the HPV vaccine to unwillingness to get the vaccine due to beliefs that COVID-19 vaccine was mixed within the vials of other routine vaccines. Findings of US-based surveys with parents have also noted changes in parental beliefs related to vaccine safety. , For some of the providers reporting no major changes in HPV vaccination uptake, this finding could be explained by consistent vaccine recommendation. As noted by a study conducted among providers in Texas, providers that often or always recommended the HPV vaccine were 9.7% less likely to report a decrease in HPV vaccination during the pandemic. Notably, PCTMs in this study highlighted that they noticed a general increase across routine vaccines. Similar to a study conducted among providers in Minnesota, participants in this study provided various perspectives regarding whether changes in vaccine hesitancy were related to hesitancy toward COVID-19 vaccines. Some participants expressed that parents were more willing to vaccinate their children since the pandemic, which is consistent with findings from another US-based study. Another theme that emerged in this study was the importance of interpersonal relationships during vaccine conversations. Similarly, studies from providers in Georgia and Tennessee noted that trusting, interpersonal relationships between PCPs and families facilitate vaccine conversations, including those involving HPV vaccination. US-based research has confirmed decreases in vaccine uptake post-pandemic. Per national estimates reported in 2024, HPV vaccination uptake has not improved since the COVID-19 pandemic while uptake for other routine childhood vaccines has recovered to pre-pandemic levels. While the literature shows that receiving a provider recommendation is a main predictor of successful HPV vaccine uptake, challenges reported by PCPs since the pandemic underscore key barriers to providing these recommendations during primary care conversations. , Challenges to having vaccine conversations, including for the HPV vaccine, reported by PCTMs as part of this study may help explain some of the reasons behind these decreases. Lessons learned from their experiences may help adapt existing vaccine communication interventions to address ongoing challenges hindering vaccine conversations and the efforts to recover vaccination coverage in the US, especially for the HPV vaccine. 

First, although the sample size was sufficient for this qualitative study, this small sample limits the generalizability of the quantitative findings shown and should not be attributed to the overall experience and vaccine recommendation behaviors of PCTMs across Pennsylvania. The convenient sampling method utilized may have led to a biased recruitment of participants that are willing to talk about HPV vaccination within the context of the COVID-19 pandemic; participants who are unlikely to talk about this topic were more likely to decline participation in the study. Hence, the findings of this study may not represent the perspectives of PCTMs that are not keen about speaking about the HPV vaccine regarding changes in vaccine conversations during the COVID-19 pandemic. This limits the generalizability of these findings as changes in HPV vaccine conversations may have been perceived differently by PCTMs based on their usual recommendation behaviors and approaches. Recall bias may have played a role in the information provided as the interviews were conducted over 4 y after the pandemic and about a year after the pandemic was dropped as a public health emergency in the US. Although recruited participants came from diverse racial, ethnic, and geographical backgrounds, there is a lack of representation from African American PCTMs, which limits its applicability to this group. Furthermore, the cross-sectional nature of this study does not allow to assess changes by phases as it depends on the recollection of experiences at one point in time after the main event of interest. In terms of strengths, participants represented different counties across Pennsylvania, which provides insight of PCTMs providing health services to minors from diverse catchment areas throughout the state. Also, participants include providers with diverse clinic roles and years of experience, offering a broader perspective of experiences with regard to vaccine conversations. Therefore, the findings of this study inform ongoing assessments being conducted in the post-pandemic context to understand changes in HPV vaccine conversations. For example, these findings may help identify best practices to vaccine conversations based on the origin of the hesitancy, such as there being too many vaccines recommended at once, concerns about vaccine components, and lack of understanding of the protection conferred by vaccines. Specifically, this study helps present communication approaches that PCTMs are using during clinical encounters since the COVID-19 pandemic. The exploration and identification of these shifts, as reported by PCTMs, help strengthen existing communication trainings tailored to primary care to post-pandemic realities and concerns. 

AppendixA_COREQ_QUAL_12_3_2024.pdf 

