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To date, there has been very little research to understand how the healthcare system affects the recommendations providers make and how those recommendations actually produce uptake of the HPV vaccine. What characteristics of the provider, parent/patient, and clinical setting can enhance or inhibit the making of the recommendation and resulting vaccine uptake? As discussed above, the message given by the provider can affect uptake, as can other provider-level characteristics, such as her own conviction that the vaccine is safe. At parent level, existing doubts about vaccines in general, or simply the inability to leave work a second time for an additional vaccine dose, can affect uptake. Within the practice setting, secondary providers, such as nurses and office staff, can also influence vaccine uptake. Imagine that the nurse who delivers the vaccine mentions that it is okay to skip one of the three vaccines recommended at this age -- the HPV vaccine; the parent might change her mind and the presence of the nurse will not equate to vaccine uptake. Also in the practice setting, if the vaccine is not in stock, the provider recommendation will not equate to vaccine uptake. At each level – provider, patient/parent, and practice setting – intermediate outcomes are needed and characteristics of each level can influence the process.
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