title: Characterizing safety-net providers' HPV vaccine recommendations to undecided parents: A pilot study.
abstract: Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations.
  
  
  
  We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination.
  
  
  
  We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale.
  
  
  
  Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction.
  
  
  
  Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.
authors.affiliation: University of Texas School of Public Health, San Antonio Regional Campus, Department of Health Promotion and Behavioral Sciences, 7411 John Smith Drive, Suite 1100, San Antonio, TX 78229, USA. Electronic address: laura.aubree.shay@uth.tmc.edu.
authors.forename: L Aubree
authors.initials: LA
authors.lastname: Shay
authors.affiliation: Texas A & M University, Department of Communication, 102 Bolton Hall, College Station, TX 77843-4234, USA; Baylor College of Medicine, Department of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA. Electronic address: r-street@tamu.edu.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Street
authors.affiliation: Southern Methodist University, Department of Psychology, PO Box 750235, Dallas, TX 75275-0235, USA. Electronic address: baldwin@mail.smu.edu.
authors.forename: Austin S
authors.initials: AS
authors.lastname: Baldwin
authors.affiliation: University of Texas Southwestern Medical Center, Department of Clinical Sciences, 5323 Harry Hines Blvd, Dallas, TX 75390-8557, USA. Electronic address: emily.marks@utsouthwestern.edu.
authors.forename: Emily G
authors.initials: EG
authors.lastname: Marks
authors.affiliation: University of Texas Southwestern Medical Center, Department of Clinical Sciences, 5323 Harry Hines Blvd, Dallas, TX 75390-8557, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA. Electronic address: simoncraddock.lee@utsouthwestern.edu.
authors.forename: Simon Craddock
authors.initials: SC
authors.lastname: Lee
authors.affiliation: University of Texas Southwestern Medical Center, Department of Clinical Sciences, 5323 Harry Hines Blvd, Dallas, TX 75390-8557, USA. Electronic address: robin.higashi@utsouthwestern.edu.
authors.forename: Robin T
authors.initials: RT
authors.lastname: Higashi
authors.affiliation: University of Texas Southwestern Medical Center, Department of Clinical Sciences, 5323 Harry Hines Blvd, Dallas, TX 75390-8557, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA. Electronic address: celette.skinner@utsouthwestern.edu.
authors.forename: Celette Sugg
authors.initials: CS
authors.lastname: Skinner
authors.affiliation: Parkland Health & Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, USA. Electronic address: sobha.fuller@phhs.org.
authors.forename: Sobha
authors.initials: S
authors.lastname: Fuller
authors.affiliation: Parkland Health & Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, USA. Electronic address: donna.persaud@phhs.org.
authors.forename: Donna
authors.initials: D
authors.lastname: Persaud
authors.affiliation: University of Texas Southwestern Medical Center, Department of Clinical Sciences, 5323 Harry Hines Blvd, Dallas, TX 75390-8557, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA. Electronic address: jasmin.tiro@utsouthwestern.edu.
authors.forename: Jasmin A
authors.initials: JA
authors.lastname: Tiro
mesh_terms: D000293:Adolescent; D002648:Child; D055088:Early Detection of Cancer; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D030361:Papillomavirus Infections / Q000517:prevention & control*; D053918:Papillomavirus Vaccines / Q000009:adverse effects / Q000627:therapeutic use*; D010290:Parents; D010342:Patient Acceptance of Health Care; D010817:Physician-Patient Relations; D010865:Pilot Projects; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D036301:Qualitative Research; D064876:Safety-net Providers; D013637:Tape Recording; D013781:Texas; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*
chemical_list: D053918:Papillomavirus Vaccines
keywords: HPV vaccination; Patient-provider communication; Provide recommendation; Qualitative analysis