Table 6.

Thematic findings and examples by levels of the social ecological framework (SEF).

Main theme and SEFalevel		Subtheme	Sample quotes
Perception of vaccine barriers
	Parents and Patients	Sexual activity and promiscuity (n=69)	“Their parents’ opinions regarding the teen’s sexuality [obviate the] legitimacy of the vaccine.”
		Vaccine refusal or reluctance (n=62)	“For some reason it is okay for women to have PAP exams but it is scandalous to get the vaccine that can prevent the cancer Pap exams detect.”
		Inadequate or incorrect parental knowledge (n=96)	“...very misinformed by relatives, or friends.”
		Low perceived risk of human papillomavirus (HPV) infection (n=67)	“They underestimate the risks of not being vaccinated. And overestimate the risks of vaccination.”
	Providers	Vaccine not a priority (n=19)	“We occasionally forget the vaccine at sick visits.”
		Not supportive of HPV vaccine (n=16)	“...[HPV vaccination] is a commercial success for HPV vaccines manufacturers; however, cervical cancer is not a pandemic disease and could be better controlled under personal choices than other diseases that [patients] must be vaccinated against.” “I live in a community where most teenagers are not sexually active until they get...It is hard to recommend a series of 3 somewhat painful shots to teenagers who are not planning to be sexually active until they get married.”
		More scientific evidence desired (n=13)	“...more science showing benefit in men.”
	Organizational	Cost (n=32)	“I recommend HPV in those that participate in VFC, but once they are 19 and older, it is too expensive.” “I’m a big proponent of vaccines, but the cost-benefit analysis of HPV just doesn’t support its widespread use. $400 is way too expensive…The HPV vaccines don’t obviate the need for pap smears, so what are we gaining here? Nothing.” “Make it free. Otherwise, I don’t have any plans to recommend it.”
		Completing follow-up doses (n=22)	“If it were not a series, they forget to finish it.” “Infrequent preventive visits. Difficulty completing the series.”
		Infrequency of visits (n=16)	“[There are] not enough well child visits to get in the entire series.”
Perceptions of vaccine improvement strategies
	Parents and Patients	Education (n=81)	“Discussion about rates of infection in Utah especially in suburban areas and discussion about cervical cancer and its causes as a television campaign.”
		Gender differences (n=23)	“Better information about genital warts, anal cancer and other diseases caused by HPV that affect boys, and can be minimized by use of the vaccine.”
	Providers	Cancer prevention focus (n=18)	“Focusing on cancer prevention ‘later in life’ is more effective—especially when the discussion can be combined with the discussion about meningococcal meningitis and tetanus/pertussis. [HPV vaccination] is just a routine part of the preteen triad of immunizations.”
		Make HPV vaccination routine practice (n=17)	“To make it more routine like it is expected to get it in medical culture rather than this optional/additional vaccine.”
		Tailored recommendation (n=23)	“Discussing the fact that [patients] can be exposed from a future husband who did not know he was infected.”
		Educational information (n=22)	“I need some information sheets, reassurance sheets, on side effects and safety, which are easy to hand out.”
	Organizational	Public policy and standing orders (n=22)	“Adding it to the list of required vaccines for junior high and high school.”

^aSEF: social ecological framework.