Table 1.

Themes and Exemplars Regarding HPV Vaccination Barriers

PARENT-CHILD DYAD	Knowledge gap “I think the consumer education, the people who need to be educated, the parents who are resistant, or the young adult who are resistant…. sometimes their readiness to learn…if they don’t want to know, they may not be open to the information.”--Community program (1) “Perhaps lack of education, lack of information. Being unclear about how to get the vaccine, where to get the vaccine.”--Professor Fear “I hear a lot of people who are concerned about vaccinations in general.”--Community program (1) “For some people, it may be understanding and trusting that it’s beneficial.”--MD “Vaccine hurts. After they get the first one, they are a little timid on #2 and #3. That’s probably the biggest comment we get from the recipients.”--Pharmacy Sex Stigma “Well boys also, I mean. It’s interesting, it seems….and we looked at our data not too long ago..it seems that parents are more concerned about giving it to girls than they are boys. (chuckle). Boys are expected to stray I guess, (more chuckle), but they don’t seem to be that concerned.”--Health Dept “And I think one of the other main hesitation points that we hear from parents is that they don’t understand why their child need to be vaccinated against a disease that is sexually transmitted at such a young age when they believe or hope that their child won’t be sexually active until later on.”--RN Healthy Population “It focuses on adolescents who don’t have to come in to the doctor’s office as often maybe unless they are doing a school physicals or things like that.”--Health Dept “Most of the children at this age don’t go to the doctor regularly, they only go for sports or when they’re sick. So the fact that if it’s not part of the regular routine of booster, it’s easily fall of the radar.”--Community program (2)
INTERPERSONAL	No Recommendation “Meaning that the physicians are not promoting the vaccine as good medicine to their patients. They have no problem promoting the other vaccines, but HPV vaccine stands alone, as you know being promoted. I think it’s a failure of physician leadership. Failure of physicians to being willing to say this is an unequivocally terrific medicine.”--MD “Immunization is not central to family medicine so they are not proactive and making strong recommendations toward all vaccines.” --Industry “The biggest barriers in my view are physicians are not recommending and not following through on vaccinations. But the problem is that the folks who need to do the vaccination are the pediatricians. Or family medicine. Most people don’t get their gyn exam until they are almost out of the window for vaccination.” --MD “They have been counseled by previous physicians in their local, rural area that they lived in. The physician advised against it. That was the barrier.”--RN Time Constraint “Providers are always difficult to reached because of their available time…. how do you reach people who are busy.”--Community program “I think that so much falls on the nurses that they don’t have the time to routinely go out their way to find these vaccine or what not.’’--Health Dept “A lot of the feedback that we got from physicians and nurses were that there wasn’t always times to talk about it and if the patient/parent didn’t bring it up, most of the time it didn’t get addressed.”--Community program (1) “One of the biggest challenges is, really has nothing to do with the vaccine itself, it’s just on top of everything else because we talk about vaccine every time - Making sure we address it, making sure one of us can do it notably our nurse who is being pulled in different directions. So our intentions are honorable. So the biggest challenge/barrier is making sure we include that in the visits as far as time.”--NP
ORGANIZATIONAL	Cost “It’s expensive, but if you have insurance it’s covered. If you don’t have insurance and you are Medicaid or un-insured and you go to the VFC then it’s provided to you based on your inability to pay. So I don’t think so, but I don’t know. Maybe that’s unknown. Maybe people don’t know what access they have if they have limited resources.”—Pharmacy “One thing that I’ve noticed, a lot of the Ob offices are not carrying the HPV vaccine…”--Health dept “Cost is a barrier, but I don’t know how much of a barrier other than access. Is it cover by Medicaid or any of the children’s program?” -Community program (1) Lack infrastructure/Champion “So the alternative is to have the insurers and/or organizations make it a performance criteria.” -MD “Currently lack infrastructure to schedule that far out for a nursing visit, lack of infrastructure to determine how is behind in immunizations, VIIS not efficient). Currently: letting them schedule them own, low number that do.”--MD “Organizations don’t place immunization as high enough of priority; more focus on chronic illnesses.”--Industry Resisting Help “Access to organization --people won’t let you in the door because (1) perception with industry that collaborating is negative (2) time constraint - providers are overwhelm with managing changes to healthcare; perception of disruption to busy schedule (3) hard to get one-on-one time with providers/doctors- perception of distrust, that there is a catch. Providers do not realize that drug industry have changed too, more collaboration rather than selling.”--Industry “And then I guess a challenge off of that is also the lack of time that I noticed with providers saying, “Well, we don’t have time to go to another system to look up record.”--Health Dept
COMMUNITY	Bad Data “One is my concern that we don’t have very good data on just how well or how badly we’re doing. A lot of it is guesstimates based on national data and or limited sources such as VIIS and the Vaccine For Kids program.”--Community program (1) “Because Virginia Immunization Information System is a voluntary system in Virginia, our rates still tend to be showing lower maybe than what the national average or what Virginia’s average are.”--Health Dept Limited Health Care Financing/Resources “Funding is definitely a challenge that changes from year to year… We also have a lot of trouble with transportation in this area. It’s very mountainous area so it’s difficult for people to get to where they need to get to.”--Health Dept “Well, we know that ethnic minorities tend to have more difficulty to access health care to begin with. [A]nd that (vaccine assistance programs) might actually promote access, but general speaking we know that low-income minorities tend to have more difficult barriers to health care both because some providers don’t take Medicaid.”--Professor No Champion “I would like to see the same amount of attention. I know it’s a little harder because the scope of it is a little bit different, but I think any attention it has gotten that way has been negative unfortunately. So basically having someone willing to fight back against that will be really nice.”--RN “I think you got to first, we live in an area with a strong, fundamental religious approach. And somehow, I think as well as nationwide this discussion of HPV has been about sex, where it should be about cancer. I think we get too many moral voices on this….I think the medical community needs to really step forward instead….”--Community program(2)
POLICY	Ineffective mandate “Other barrier is that it’s not a school requirement vaccine in Virginia. So parents thinking, ‘Well if I don’t have to have it, then I don’t need to get it.’ And medical providers thinking also, ‘Well if it’s not required by schools…’ and so it’s being treated more as a optional vaccine…”--Health Dept “There’s not accountability for that requirement so that bring the message to parent and they seem to interpret it as that maybe this vaccine is not as important as some of the other school-required vaccines.”--RN “Currently the mandate is only for girls, not for boys. And while parents can opt out of the mandate, there’s no way to determine it in the data versus, in the tracking, if a parent opt out because they chose not to or were they not even asked about immunization for their child.”--Health Dept Failed Medicaid Expansion “Since the state of Virginia chose not to expand Medicaid under the Affordable Care Act, we have a lot of people kinda trapped. They’re making a little too much for Medicaid but they don’t make enough to be able to go into the health exchange of the Affordable Care Act”--Community program (2) “The big challenge is there are people who don’t have any healthcare at all or the people that fall through the crack because they don’t have Medicaid Expansion. Vaccinations are expensive.”--MD Political/Legislative Climate “I do think that the resistance to the mandate has been a problem and there has been numerous efforts over the years to get that off the book. So any attempt to do better legislatively risk losing what we got. I think that some of the conservative elements, and I don’t mean political conservative, but just very conservative religious conservative. What family should do, and not what society should do …that those are barriers we’re going to have to deal with in large part of the commonwealth and in this catchment area.”--Community program (2)

Note: RN = Registered Nurse; NP = Nurse Practitioner; MD = Medical Doctor; VIIS = Virginia Immunization Information System