Benefits, challenges, and strategies related to using presumptive recommendations for HPV vaccination: A qualitative study with rural and non-rural-serving primary care professionals

ABSTRACT

HPV vaccination coverage remains far below the national target of 80% among US adolescents, particularly in rural areas, which have vaccine uptake rates that are 10% points lower than non-rural areas on average. Primary care professionals (PCPs) can increase coverage by using presumptive recommendations to introduce HPV vaccination in a way that assumes parents want to vaccinate. Through semi-structured interviews, we explored PCPs’ experiences and perceptions of using presumptive recommendations in rural- and non-rural-serving primary care clinics in North Carolina. Thematic analysis revealed that most PCPs in rural and non-rural contexts used presumptive recommendations and felt the strategy was an effective and concise way to introduce the topic of HPV vaccination to parents. At the same time, some PCPs raised concerns about presumptive recommendations potentially straining relationships with certain parents, including those who had previously declined HPV vaccine or who distrust medical authority due to their past experiences with the healthcare system. PCPs dealt with these challenges by using a more open-ended approach when introducing HPV vaccination to parents. In conclusion, our findings suggest that PCPs in both rural and non-rural settings see value in using presumptive recommendations to introduce HPV vaccination, but to adequately address concerns and ensure increased HPV vaccine uptake, PCPs can use simple and culturally sensitive language to ensure fully informed consent and to maintain parental trust. And to further strengthen HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach, in discussing HPV vaccinations with hesitant parents.

KEYWORDS:

• HPV vaccine
• HPV vaccination
• HPV vaccine communication style
• presumptive recommendation
• announcement approach

Introduction

HPV vaccination coverage in the US remains far below the Healthy People 2030 target of 80%.¹ Despite national guidelines for routine HPV vaccination at ages 11–12, only 50% of 13-year-old were up-to-date on the multidose series by 2022.² Furthermore, coverage is persistently lower in rural areas, where HPV vaccination rates are 10% points lower than in non-rural areas.^3–5

Provider and health-system level strategies can increase HPV vaccine uptake, with research suggesting that provider communication is especially important.^6–9 For example, a recent meta-analysis of 59 studies found that receiving a primary care professional’s (PCP) recommendation was associated with 10 times higher odds of initiating the HPV vaccine series.¹⁰ Presumptive recommendations, which involve a provider assuming a parent is ready to vaccinate their adolescent and presenting vaccination as the default choice, are particularly effective in increasing the HPV vaccine uptake.^10–16 In giving a presumptive recommendation, a provider might say “Andrew is 11. He is due for three vaccines. Today, he will get vaccines against meningitis, HPV cancers and whooping cough.”^6,17,18 Findings from randomized controlled trials (RCTs) have shown that providers trained to use presumptive recommendations have increased HPV vaccine uptake compared to other communication styles.^12,16,17 For example, results from the RCT by Brewer and colleagues revealed that providers who received presumptive recommendation training had five percentage points higher HPV vaccine initiation rates than those trained in using a conversational style (95% CI: 1.1% to 9.7%).¹⁷

In contrast to strong evidence on the effectiveness of presumptive recommendations, less is known about PCPs’ perceptions of and experience implementing them. Although survey research finds that there is high acceptability for using presumptive recommendations,¹⁹ few studies have described how PCPs may tailor the presumptive approach to their patient population. Furthermore, despite the significantly lower HPV vaccination rates among rural adolescents, to our knowledge, no studies have investigated rural and non-rural differences in the experiences and challenges of an entire primary care team (physicians, nurses, and medical assistants (MAs)) in using the presumptive recommendation during routine visits. Therefore, this analysis aimed to understand PCPs’ experiences and challenges using presumptive recommendations when introducing HPV vaccination to parents of adolescents and how these perceptions might differ by rurality in the US.

Materials and methods

Study population & recruitment

Our study team consisted of faculty, staff and graduate research assistants with varied qualitative research experience (LPS, TY, CBB and OOO). We conducted 45- to 60-minute semi-structured interviews via a videoconferencing platform with 36 PCPs (including physicians, nurses, nurse practitioners, and MAs) in North Carolina (NC) who were involved in administering HPV vaccine to adolescents. We categorized interviewees currently practicing in rural-serving versus non-rural-serving clinics. Rural-serving clinics included clinics located in a rural county based on Rural-Urban Continuum Codes (i.e., codes 4–9),²⁰ as well as clinics located in non-rural counties with the majority of patients coming from rural counties (as reported by interviewees). Non-rural serving clinics included those located in non-rural counties with the majority of patients coming from non-rural counties. We purposively sampled PCPs according to their medical training and clinics’ rurality using informational e-mails and flyers distributed to clinics, health systems, and professional organizations (e.g., North Carolina Pediatric Society, Academy of Family Physicians and Area Health Education Centers (AHEC)) across NC. We also recruited PCPs through snowball sampling, where interviewees referred their colleagues to the study. All participants gave verbal informed consent and received a $100 gift card for their time. The University of North Carolina Institutional Review Board approved this study (IRB #21–3090).

Data collection

The interview guide (Appendix A) was developed with the goal of better understanding the training PCPs received related to communicating about HPV vaccination and PCPs’ experiences and challenges in using presumptive recommendations to talk about the HPV vaccine. In the interviews, we probed on strategies PCPs have used previously to modify their presumptive recommendations about the HPV vaccine with parents, including among those who were vaccine hesitant.

Interviews were conducted by an experienced interviewer (TY) between May 2022 and July 2022 until thematic saturation was achieved in relation to our primary research question.^21,22 Screener questions were administered to all participants to obtain demographic information (e.g., race, ethnicity, gender, medical training, and years in practice) and HPV communication training history. All interviews were audio-recorded and transcribed verbatim.

Data analysis

The approach in our study is based on the constructivist paradigm which involves the different interpretations of a phenomenon among people which could be influenced by their cultural or social perspective.²³ We conducted thematic analysis and developed our codebook using an iterative hybrid approach that was primarily inductive.²⁴ We included codes we determined a priori that were informed by our research question and interview guide (e.g., past/current use and benefits of a presumptive recommendation). We also took notes consisting of summaries from our initial reflections from the interviews to serve as an audit trail. Interview transcripts were coded using MAXQDA Plus 2022 version 22.2.0 software.

Specifically, in the first-cycle coding, with supervision from LPS, a faculty with extensive qualitative research experience, OOO and CBB added to the codebook (Appendix B) using codes identified through a preliminary review of 24 transcripts (e.g., populations for which the presumptive recommendation works/does not work well, modifications of presumptive recommendations, etc.). OOO, CBB and LPS met to ensure agreement in the appropriate application of codes and to further refine the codebook. The final codebook can be found in Appendix B.

In the second cycle coding, CBB and OOO piloted the final codebook on two transcripts and met to ensure consistent code application and resolve discrepancies in code definitions. Then, CBB and OOO divided all the transcripts (n = 36) and coded them independently. To confirm consensus in the coding process, CBB and OOO regularly met to review each other’s coding to ensure consistent code application and interpretation and resolve discrepancies. Next, CBB and OOO identified overarching themes from the existing codes and compared them across provider type and rurality. Lastly, coded excerpts were reviewed to identify representative quotations,^25,26 and we adhered to the Standards for Reporting Qualitative Research (SRQR) in this manuscript.²⁷

Results

Participant characteristics

Our study sample consisted of 21 rural-serving and 15 non-rural-serving PCPs involved in HPV vaccination. Participants were practicing in federally qualified health clinics (FQHCs) (n = 21, 58%), independent physician-owned practices (n = 10, 28%) or health system-affiliated clinics (n = 4, 11%) or another type of primary care clinic (n = 1, 3%) across NC. Most of our sample identified as women (n = 32, 89%), White (n = 27, 75%), non-Hispanic or Latino (n = 33, 92%), and had been practicing for more than 5 years (n = 23, 64%). We achieved a good distribution of PCPs with our sample comprising of physicians (n = 20, 56%), nurses (n = 10, 28%) and MAs (n = 6, 16%) (Table 1).

Table 1. Interviewee characteristics (N = 36).

	Rural serving (n = 21)	Non-rural serving (n = 15)
	n (%)	n (%)
Gender
Woman	18 (86)	14 (93)
Man	2 (10)	1 (7)
Non-binary	1 (4)	0 (0)
Race
White	18 (86)	9 (60)
Black	2 (10)	5 (33)
Asian	1 (4)	1 (7)
Ethnicity
Hispanic/Latino	2 (10)	1 (7)
Non-Hispanic/Latino	19 (90)	14 (93)
Medical training
Physician	11 (52)	9 (60)
Nurse	6 (29)	4 (27)
Medical assistant	4 (19)	2 (13)
Practice type
Federally qualified health center (FQHC)	13 (62)	8 (53)
Independent physician-owned practice	5 (24)	5(33)
Health system affiliated practice	3 (14)	1 (7)
Another primary clinic type		1 (7)
Years in practice
<5	9 (43)	4 (27)
5 to 9	4 (19)	3 (20)
10 to 14	5 (24)	3 (20)
15 to 19	2 (10)	3 (20)
>19	1 (4)	2 (13)

Themes

Six themes were based on how PCPs viewed the benefits and challenges of using a presumptive recommendation and how they modified this approach or switched to a different communication style in some circumstances. While these themes were similar across rural- and non-rural serving providers, some of them were more expressed by rural-serving PCPs. (Appendix C).

Benefits and facilitators of presumptive recommendations

Theme 1:

Most PCPs viewed presumptive recommendation favorably and described using the style as their routine approach.

Most rural (n = 20/21, 95%) and non-rural serving PCPs (n = 15/15, 100%) said a presumptive recommendation was their most frequent communication style when approaching HPV vaccination with parents.

It [presumptive recommendation] is the most effective strategy that I have found kind of across the board if I had to only have one strategy. (#20- Physician, rural-serving clinic)

A primary benefit of using a presumptive recommendation noted by interviewees was that it allowed them to present HPV vaccine as part of routine vaccination, without differentiating the HPV vaccine from other vaccines required by schools.

I kind of couch [adolescent vaccination] as, ‘Okay, this is the 11-year-old checkup, there are three vaccines for us to talk about.’ And just sort of boom, boom, boom, like, these are the three [vaccines] that I recommend. They’re all equally important in my eyes. And I don’t really distinguish, like, this is the one school requires, this is not required by school. I just sort of say, ‘This is what we do at 11. (#14- Physician, non-rural-serving clinic)

PCPs noted that a presumptive recommendation provided a concise and direct way of introducing HPV vaccine.

Theme 2:

PCPs, particularly those in rural-serving clinics, agreed that establishing a parent-provider relationship rooted in trust and open communication facilitated their presumptive recommendation of HPV vaccination.

Several PCPs practicing in rural clinics (n = 7/21, 33%) observed that their presumptive recommendation was better received by parents with whom they had a long-standing, trusting relationship.

I have the long-term staff, so they build these relationships with these families. And [families] tend to trust that clinical staff member who is relaying that information because that’s who they see every time they come in. You’ve got your nurse or your medical assistant who is advising you on these vaccines plus your doctor, and they’re a team working together. (#23- LPN, rural-serving clinic)

In addition, rural-serving PCPs and a non-rural serving PCP noted the importance of speaking about the HPV vaccine in simple, nonscientific terms and leaving room for parents to ask questions or raise concerns. Related to this sentiment was providers’ belief in the importance of pairing the presumptive recommendation with education about the HPV vaccine.

I guess for me personally, I have always been very conscious about how I talk to families. And so, I always try to talk in simple terms, slowly, clearly no matter who I’m talking to, and again, mostly because of the population of patients that I’ve worked with. That’s just, again, muscle memory and how I’m programmed to talk as well. But I never want to assume. Even if there is a family that is super wealthy and maybe have gotten every single vaccine before and no problems, I never want to assume that there won’t be any miscommunications or misunderstandings. (#36, Physician, non-rural-serving clinic)

Theme 3:

Few PCPs noted increased receptivity to the presumptive recommendation for parents who were younger or had to travel farther for care.

A rural-serving PCP noted that the presumptive recommendation worked particularly well with younger parents who had received the HPV vaccine themselves and thus were more familiar with it.

[With] my teen parents, I do the presumptive approach really easily. I think [it’s] because all of these things are still familiar to them. … With [one mom in particular], she’s just, like, ‘Whatever we’re supposed to be doing let’s do it. Whatever vaccine, okay, we’ll do that one.’ And she’s familiar with all of that because it’s only been a few years since she had her HPV vaccine. … It’s generational. I think the Gen Z population is a lot more invested in their community and outcomes. (#30- Physician, rural-serving clinic)

Interestingly, another rural-serving PCP noted that travel distance also influenced parental willingness to have their children receive the HPV vaccine following a presumptive recommendation.

I think in the rural areas, the rural area parents are more on board to get whatever vaccines are needed at their [children’s] visits, because they do live in a rural area and it’s harder for them to get these vaccines. So when they’re in the office, they’re willing to get as many as needed. Versus the ones who have direct care, easy means to get in care. (#5- MA, rural-serving clinic)

In these ways, PCPs reports suggested that parents’ age and geographic location may play a role in the awareness of HPV vaccine and accessibility to HPV vaccine, which impacts acceptance of providers’ HPV vaccine recommendation.

Challenges of using presumptive recommendations

Theme 4:

Even among PCPs using presumptive recommendations, several voiced concerns about parents’ reactions to medical authority and obtaining fully-informed consent from parents.

Although most PCPs had favorable views about the presumptive recommendation, several PCPs, especially rural-serving ones (n = 10/21, 48%), mentioned the potential for presumptive recommendations to exacerbate parent-provider power dynamics and contribute to mistrust of the healthcare system. This sentiment was expressed to a lesser degree by non-rural serving PCPs (n = 6/15, 40%).

I do think that [presumptive recommendation] is a little bit more of a paternalistic approach to medicine, which generally is not [the] approach that I like to take with most things patient related and especially for people who have had poor experiences with the health care system. It can, I think, at times be a little bit jarring to have that paternalistic approach taken. (#7- Physician, rural-serving clinic)

A few PCPs mentioned that the presumptive recommendation had the potential to make it more difficult for parents to distinguish HPV vaccine from other vaccines when consenting to vaccination, leading to concerns about ensuring full parental understanding and consent when using a presumptive recommendation.

What [a presumptive recommendation] ends up doing is HPV [vaccine] becomes a blur when they’re hearing about meningitis and everything else. And so, perhaps, that’s not a good way to fully inform a parent and get their consent. (#4-Physician, rural-serving clinic)

PCPs underscored the importance of making sure parents understood all aspects of the clinic visit, especially when including HPV vaccine with other routine vaccines so that parents were fully informed before consenting to vaccination.

Theme 5:

PCPs perceived presumptive recommendations as having lower acceptability for certain populations, including Appalachian, historically marginalized, and vaccine hesitant parents.

Rural (n = 4/21, 19%) and non-rural serving (n = 5/15, 33%) PCPs’ concerns with using presumptive recommendations were heightened when they described their interactions with parents with past negative experiences in the healthcare system. This sentiment was particularly observed for parents of color, migrant populations, and Appalachian residents.

I think Appalachian folk in general do not respond necessarily to being told what [to do]. And there’s a long history of being taken advantage of, especially in the opioid epidemic in this region. And so I find that telling them what we do just kind of as prescriptive doesn’t get you very far personally. (#30- Physician, rural-serving clinic)

With folks who have historically experienced painful things in the healthcare system, particularly folks of color, I try to be very mindful of, you know, using language and tone that doesn’t make it seem like I’m, like, sneaking something in. (#27- Physician, non-rural-serving clinic)

Additionally, more rural-serving PCPs expressed concerns that delivering a presumptive recommendation to parents who have a general anti-vaccine sentiment or have previously declined HPV vaccine could strain the parent-provider relationship because parents might perceive that their PCP was not attentive during previous conversations which might threaten the rapport between parents and PCPs.

Yeah. I mean, like I said the parents that are already vaccine hesitant, I have found that [a presumptive recommendation] is a breach in trust, or it might seem like I have forgotten what they’ve told me in previous visits, and so [a presumptive recommendation] sort of breaks their understanding of our relationship. And so, I have found that that is not the approach to take in that specific population. (#20, Physician, rural-serving clinic)

Though PCPs agreed that presumptive recommendations were effective and efficient, they also acknowledged that it may not be the best approach in all circumstances or for all parent groups.

PCPs’ modifications of presumptive recommendations

Theme 6:

Some PCPs explained certain circumstances where they use a different approach like a more open-ended approach or an ambiguous recommendation instead of a presumptive recommendation.

Majority of rural (n = 13/21, 62%) and non-rural serving (n = 9/15, 60%) PCPs described the need for more education due to parents potentially not knowing what HPV is or not understanding the importance of the HPV vaccine, especially for parents who had low health literacy levels or limited HPV awareness. In such situations, using only a presumptive recommendation might not work well, and as a result, these PCPs defaulted to educational or direct question approach. For example, PCPs would first ask parents if they knew about HPV vaccine and then would provide some education on the vaccine.

Yeah. When I practice in a more rural setting, I tend to do the more educational approach more often. And I think it’s really important in rural populations or underserved populations or folks that haven’t had good access to healthcare or [have not heard of certain things] to practice, rather humbly and not ever make them feel like it’s their fault or [that] they should know things. (#29- Physician, rural-serving clinic)

Relatedly, rural-serving PCPs also mentioned that they used an open-ended style when meeting parents for the first time or they often veered away from the presumptive recommendation approach if they sensed hesitancy from the parent’s body language during an appointment.

If it’s like my first time meeting a family or they’re like brand new to our clinic and establishing care and we’re trying to get them caught up on vaccines for school and HPV isn’t necessarily required, doing—maybe doing a more open-ended approach there since I’ve never met them. (#7, Physician, rural-serving clinic)

In summary, to some extent, PCPs acknowledge that there’s some value in refraining from using the presumptive recommendation and switching to another communication style when introducing HPV vaccination with certain parents.

Discussion

Our study examined rural- and non-rural-serving PCPs’ perspectives on using a presumptive recommendation in introducing the HPV vaccine to parents of adolescents. Although rural and non-rural-serving PCPs expressed similar sentiments about presumptive recommendations, more rural-serving PCPs emphasized that establishing parent-provider trust and proper communication facilitated their recommendations, but parental reactions to medical authority hindered their use of presumptive recommendations. Similar to previous research, rural and non-rural serving PCPs described using a presumptive recommendation as their routine approach and perceived it as effective in promoting HPV vaccine uptake.^{17,19,28,29,30} The challenges some PCPs, especially rural-serving PCPs, mentioned with using a presumptive recommendation included the perception that it could exacerbate patient-provider power dynamics and that the assumption of prior HPV vaccine knowledge was potentially detrimental to parent-provider communication and trust. Therefore, to address the challenges of using a presumptive recommendation, PCPs can combine a provider’s presumptive recommendation and more parental engagement (i.e., using a shared decision-making communication style), which could also address the concern expressed by rural-serving PCPs of obtaining fully informed parental consent.

In particular, our study’s findings on the challenges of using the presumptive recommendation may be addressed through employing the Announcement Approach, an evidence-based three-step communication strategy developed by Brewer and colleagues,^17,19,28,31 In addition to the presumptive recommendation, the Announcement Approach includes two more steps. If a parent is hesitant, the PCP inquiries about the parent’s primary concern and provides evidence-based information to address the expressed concern (“connect and counsel”).¹⁸ Lastly, in the event parents decline HPV vaccination, the PCP informs the parent that they will continue to discuss the HPV vaccine at the next visit (“try again”).^18,29,32 Having the PCP preemptively mention that they will continue discussing HPV vaccine at the next visit may reduce the perception that the provider has forgotten about prior HPV discussions. Moreover, follow-up counseling is more likely to lead to the acceptance of HPV vaccine; one study found that over two-thirds (69%) of parents who had initially declined HPV vaccine ultimately got the vaccine for their adolescents or planned to do so.³³

More specific to our study, to address PCPs’ concerns of presumptive recommendations leading to resistance to medical authority, the “connect and counsel” step of the Announcement Approach could be utilized to facilitate better parental engagement during HPV vaccine discussions.¹⁸ And for PCPs who reported presumptive recommendations might not work with certain parents (e.g., vaccine hesitant parents, Appalachian residents), by informing the parent that HPV vaccine discussion could be revisited at another time (“try-again” step), PCPs demonstrate that the parent’s choice is being respected which could potentially increase parental cooperation and HPV vaccine acceptance later.¹⁸

Both rural and non-rural serving PCPs in our study felt that using a presumptive recommendation with parents who have had poor past healthcare experiences (including individuals in Appalachia and people of color) could affect parents’ receptivity to HPV vaccination. Therefore, to foster more cooperation and acceptance of HPV recommendations from these populations, it could be beneficial if PCPs acknowledge parents’ lived experiences of medical injustice,^34,35 use culturally sensitive and acceptable language^35–37 and build and maintain trust with parents.^35,37,38 Due to some of the challenges with using presumptive recommendations, some PCPs shifted to a more open-ended or direct question approach while others spent more time on HPV vaccine education. These strategies utilized by PCPs have yielded mixed results in past research. For example, multiple studies have shown that a more open-ended approach led to parents declining HPV vaccine.^11,14,17,28 On the other hand, other studies showed that strategies that involve pairing presumptive recommendations with HPV vaccine education (which corresponds to the “counsel and connect” of the Announcement Approach)^18,29,32 were successful in increasing HPV vaccine uptake.^29,39,40 In particular, higher HPV vaccine acceptance occurs when parents’ questions and concerns are addressed.²⁹ Hence, in situations where PCPs do not feel comfortable using a presumptive recommendation in talking about HPV vaccine, such as when meeting a parent for the first time, they can shift to a communication style that seeks to better understand the parent’s stance on HPV vaccine as well as better engage with the parent which aligns with the “connect and counsel” step of the Announcement Approach.¹⁸ Additionally, it is essential that rural-serving PCPs use simple and plain language when discussing HPV vaccine with parents, so as not to lose parents with low health literacy or limited knowledge about HPV vaccine.¹⁴

Relatedly, in addition to provider-level strategies (HPV vaccine communication techniques) in increasing HPV vaccine uptake, providing more education on the importance of HPV vaccination among parents and adolescents, as well as changes at the policy level that encourage widespread access to HPV vaccine could potentially improve HPV vaccine coverage.^41,42 In sum, increasing HPV vaccine uptake requires a multipronged approach that includes policy-level changes, provider-level strategies and increased HPV vaccine education for parents and their adolescents.

Strengths and limitations

Our study’s primary strength was the inclusion of rural-serving and non-rural-serving PCPs (physicians, nurses, medical assistants) which allowed for a rich variety of experiences with the presumptive recommendation. Our study addresses a gap in the literature by investigating PCPs’ perceptions and experiences in using a presumptive recommendation in diverse practice settings. Understanding PCPs’ perspectives about a presumptive recommendation will influence the future use of this approach in discussing the HPV vaccine and ultimately impact HPV vaccination rates. Another strength was our approach of using a combination of inductive and deductive coding styles to analyze the interviews, which ensured a more comprehensive reporting of our findings.

Our study also had some limitations that should be noted. First, we did not include parents’ perspectives about receiving a presumptive recommendation. However, our study still yielded important results with the potential to positively influence PCPs’ HPV vaccine communication behaviors with parents. Another limitation is the risk of social desirability bias, where interviewed PCPs may have expressed what they thought would be viewed favorably by others. Third, our definition of rural serving was partly based on PCPs’ self-reports of parents’ counties of residence, which is not an exact measure. Lastly, our study focused on PCPs in NC and thus may not generalize to the experiences of PCPs in other states, especially given the differences in states’ HPV vaccination coverage (NC-68% vs US-62%).⁴³ Nevertheless, we believe our findings provide valuable information with the potential to positively influence PCPs’ HPV vaccine communication and thus uptake.

Conclusion

Rural and non-rural-serving PCPs viewed a presumptive recommendation as an effective strategy and agreed that an established parent-provider relationship and using plain language to introduce HPV vaccine worked well. However, more rural-serving PCPs also perceived it as having the potential to increase parent-provider power differential and breed mistrust in parents who initially declined the HPV vaccine or had prior poor experiences with the healthcare system. To increase provider-parent partnership, better navigate the challenges in using presumptive recommendations and encourage greater HPV vaccine uptake, PCPs should use culturally sensitive language that acknowledges parents’ unique lived experiences to maintain trust and seek to address parental concerns about HPV vaccine by providing evidence-based HPV education during HPV vaccine discussions. PCPs should also use nonscientific words and check that parents fully understand all clinic activities before providing HPV vaccine to ensure fully informed parental consent. Additionally, to further facilitate HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach in discussing HPV vaccinations with hesitant parents.

Further, future research should investigate parents’ experiences with the presumptive recommendation and enhancements or strategies that can make implementing other effective communication styles (the Announcement Approach) acceptable and effective in diverse practice settings.

Author contributions

Conceptualization, S.B.W., S.O., L.P.S., C.B.B., O.O.O., T.Y.; Methodology, O.O.O., C.B.B., L.P.S., T.Y.; Software, O.O.O., C.B.B., L.P.S.; Data Analysis, O.O.O., C.B.B.; Writing-original draft, O.O.O., C.B.B., L.P.S.; Writing-review and editing, S.B.W., S.O., M.B.G., L.P.S., C.B.B., O.O.O., J.Y., T.Y., C.H; Supervision, S.B.W., S.O., M.B.G., L.P.S.

Acknowledgments

We would like to thank our participants for their time and for sharing their perspectives in this study. We also thank Erin Laurie-Zehr for proofreading the article before submission.

Disclosure statement

Stephanie B Wheeler (SBW) has received salary support paid to her institution for unrelated studies from AstraZeneca and Pfizer. Lisa Spees (LPS) has received salary support paid to her institution for an unrelated study from AstraZeneca. Other Authors have no disclosures to report.

Data availability statement

The data used for this study is confidential and cannot be shared.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2347018.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This study was supported by the National Cancer Institute of the National Institutes of Health under Award Number [P01CA250989]. This manuscript’s content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.