HPV vaccination prevents the majority of HPV cancers [1], but vaccine uptake remains suboptimal [2]. One factor contributing to low uptake is parental refusal and intentional delay (or “declination”) of HPV vaccination, which ranges from 30% to 36% in national surveys of US parents [3, 4]. This level of declination is far higher than for other adolescent vaccines, such as tetanus, diphtheria, and acellular pertussis (~2%) or meningococcal vaccine (5%) [5]. Although research consistently demonstrates the importance of providers in initially recommending HPV vaccination [6-9], little is known about how providers can effectively encourage “secondary acceptance,” or HPV vaccination at a later visit, among those who initially decline.

Providers can encourage parents who initially decline vaccination for their child through actions such as responding to declination during the visit or following-up after the visit. Existing research suggests that additional action from a provider may be effective at increasing HPV vaccination at a later timepoint [10]. For example, one study found that parents had higher odds of secondary acceptance if they initially received a high-quality HPV vaccination recommendation and if they received follow-up counseling from a provider. However, only about half of parents who declined HPV vaccination (52%) reported receiving follow-up counseling [10]. Providers frequently report offering parents reassurances of safety, providing written information and asking questions to probe concerns [11]. To date, whether and how these specific actions are associated with parents’ HPV vaccination perceptions and behavior is unknown.

The Increasing Vaccination Model offers a useful framework to understand how provider communication might increase secondary acceptance [12]. This model proposes that three general psychological principles motivate vaccination: 1) thoughts and feelings, such as risk appraisals and vaccine confidence; 2) social processes, such as social norms, altruism; and 3) direct behavior change, such as reminders and prompts, that leverage favorable intentions to vaccinate without changing thoughts and feelings. Provider response and follow-up to parental declination can address these psychological processes. For example, a provider could address thoughts and feelings by actively responding to parents’ questions and concerns during the visit when parents decline HPV vaccination. Providers can also follow-up after the visit with reminders that cue parents to action in ways that promote direct behavior change. Thus, a provider may be able to increase secondary acceptance through an active response during the visit or follow-up after the visit. The Increasing Vaccination Model suggests direct behavior change as the most effective mechanism by which to intervene to improve vaccine uptake, but whether that is true in the case of secondary acceptance has never been tested.

To better understand how providers can encourage secondary acceptance, this study sought to characterize how providers respond during the visit and follow-up after the visit to parental declination of HPV vaccination and to determine how a provider’s actions upon parental declination are associated with secondary acceptance. We also sought to compare what parents reported receiving in terms of response and follow-up upon declination to what they wanted to receive. Understanding how providers can effectively communicate with parents who decline vaccination is critical to ensuring that providers deliver quality care and maintain rapport with parents.

Using data from a national sample, we found that only about one-third of parents received an active response to HPV vaccination declination during their visit or follow-up after their visit. Follow-up after the visit was associated with secondary acceptance, although an active response from a provider was not. We also found more parents wanted an active provider response and follow-up compared to those that reported receiving one. Finally, relatively few parents reported experiencing discomfort during the visit or negative decisional affect.

Our study suggests that follow-up after the visit may be a crucial time for intervention to increase HPV vaccination coverage. Follow-up, which most often consisted of the provider discussing HPV vaccination at the next visit, was associated with secondary acceptance of HPV vaccination. This finding is consistent with an earlier study that found that follow-up counseling at a later visit was associated with increased odds of secondary acceptance [10]. Aligned with the Increasing Vaccination Model [6], the provider follow-up actions we measured (i.e., bringing up vaccination at the next visit, scheduling another visit, or sending a reminder) may change behavior by cuing parents with existing favorable intentions to vaccinate. The additional follow-up may have re-emphasized the importance of vaccination while also respecting parents’ wish for more time to make a decision.

Notably, we did not observe an increase in secondary acceptance with an active response during the visit. Some of the provider active responses may have been attempting to change parents’ thoughts and feelings, which has shown less promise than attempts to directly intervene on behavior, such as sending reminders [12]. Providers may not be responding effectively enough to sufficiently change thoughts and feelings in a fashion that would lead to secondary acceptance. Providers often respond to parental requests to delay HPV vaccination in a manner that suggests vaccination is optional and not urgent [19] or that gives parents implicit permission to delay HPV vaccination [20]. Thus, providers who engage in an active response (e.g., giving more information, offering to talk at a later visit) may also be inadvertently using language that diminishes the vaccine’s importance. Alternately, providers who are too assertive may unintentionally cause reactance, in which people act in opposition to health messages as a means of retaining control [21]. Several promising communication techniques to address vaccine hesitant parents exist, including motivational interviewing, although none have yet been evaluated in isolation from multicomponent HPV vaccination interventions [6, 22].

Our findings also suggest that parents who initially decline HPV vaccination would like for a provider to respond and follow-up more often than they actually do. A higher proportion of parents endorsed “giving more information” and “follow-up at the next visit” as actions a provider should take compared with the proportion of parents that reported their provider took those actions. These findings suggests that many parents are open and receptive to additional response and follow-up from providers when they initially decline HPV vaccination. The American Academy of Pediatrics (AAP) recommends that providers encountering parental declination should listen respectfully to parents to understand their concerns and engage in non-confrontational dialogue about vaccine safety and the risks and benefits of immunization [23]. The AAP also notes that providers can give more information or ask the parents to sign a waiver at the provider’s discretion. Our study suggests that providers infrequently engage in these actions, and their association with secondary acceptance is yet to be fully understood. The low proportion of parents reporting that their provider engaged in active response and follow-up is striking, given that almost all pediatricians report encountering parents hesitant about vaccination [24].

Our study also examined the role of negative decisional affect and discomfort during the visit in parental declination. Few parents reported experiencing negative decisional affect or discomfort with the visit, and the most common response was feeling unsure, which could potentially indicate that parents were appropriately contemplating a provider’s advice. Stronger negative decisional affect, such as feeling worried or annoyed, was less commonly reported. The infrequency of strong negative decisional affect and discomfort with the visit among parents should ease concerns that some providers have about the potential for confrontational, timeconsuming conversations surrounding HPV vaccination due to parents’ opposition [25, 26].

Our study points to several potentially fruitful areas for future research. Future studies should examine whether specific aspects of a provider’s active response (e.g., specific messages) or follow-up are more successful than others at increasing secondary acceptance. In our sample, few parents received reminders or had an additional visit scheduled to talk about vaccination. Understanding whether these specific actions are effective follow-up provider actions would identify specific, actionable strategies that providers can use to increase secondary acceptance. Use of reminders for HPV vaccination have shown some, albeit inconsistent, promise at increasing HPV vaccination initiation and completion in clinical trials, suggesting that this approach may be a useful strategy for increasing secondary acceptance [27-29]. Future research could also examine whether concordance between a provider’s response to HPV vaccination declination and a parents’ preferred response could increase secondary acceptance.

Strengths of this study include a national sample and a focus on a novel and understudied aspect of HPV vaccination (parents’ report of provider response to HPV vaccination declination). The major limitation of this study is its retrospective, cross-sectional design, which precludes assertations regarding causal inference. Although surveying parents on their affect and response to a patient-provider conversation separately from the conversation may not be possible, measuring whether change in the outcome came after the patient-provider conversation could strengthen the ability to make causal inferences. Additionally, the self-reported nature of HPV vaccination status and parents’ decision during the first conversation is subject to recall bias. Depending on a child’s age, the initial discussion could potentially have occurred several years prior to the survey, and parents may not accurately recall their initial decision as well as the emotions and comfort with the provider. Furthermore, parents who had a more recent discussion with their provider may not have had sufficient time to either receive provider follow-up or to vaccinate their child after initially declining. Likewise, although self-report of HPV vaccination initiation is fairly reliable [30], it is subject to error and recall bias. Use of an online survey panel may limit appropriateness of generalizing study findings to other populations (particularly less affluent populations). For the provider active response and provider follow-up variables, parents could have selected “none of these” if their provider engaged in another response or follow-up action that was not listed on the survey. For several negative decisional affect items (e.g., worry or fear), we do not know whether parents felt the negative affect concerning vaccination (e.g., worried about the harms of vaccination) or concerning the failure to vaccinate (e.g., worry about their child getting cancer). Finally, although this study focused on parents’ perspectives, provider perspectives are also important to consider when assessing associations between provider actions and secondary acceptance.

HPV vaccination declination is a pressing public health problem. Our study underscores the urgent need to understand how providers can effectively communicate with parents who decline HPV vaccination. The majority of parents who decline do not receive an active response from their provider during the visit or follow-up after the visit, although they are receptive to such actions and rarely report experiencing discomfort with the visit or negative decisional affect when receiving such actions. Follow-up at the next visit emerged as a particularly salient action that more providers could potentially incorporate into clinical care.