Table 2. Interview themes within the multi-theory model constructs, and participants' quotes.

Constructs	Themes	Quote
1. HPV Knowledge	(a) Transmission	“I have heard about the HPV virus as a type of virus that can cause cervical cancer and also other types of cancer. I also heard that it can be transmitted sexually. And also, during childbirth, it can also be transmitted from the mother to the infant.” (Group 1, Participant 2).
	(b) Lack of Data	“We don’t have data specifically on HPV. I think once it is viral, it mimics characteristics of any other viral so I think we just lump them together and reporting is a problem so if education goes up and the reporting patterns changes then we can report on it really.” (Group 2, participant 5) “Few studies have been done in this area and the other side is that people are not actually looking for it to quantify the disease burden.” (Group 2, participant 4)
2. HPV Vaccination Knowledge	(a)Target population	“Every woman who is sexually active or every young girl who is growing up should be vaccinated to prevent it. It is not only who is sexually active in some way you might get it in another way or another form which are probably they may have a small percentage so somehow they might be vaccinated; everybody must be vaccinated.” (Group 2, participant 1). “People with immunocompromising conditions like people living with HIV (Group 1, participant 7). “Ladies or girls between the ages of 11 and 12 are most advised to get the vaccinations, so at their adolescent age.(Group 1, participant 6)” “…The focus should be on the youth, when you analyze sexual activeness with age categorization, you will see that youth dominates so if the vaccination can target the youth I think it will be proper.” (Group 2, participant 5)
	(b) Schedule dose	“The vaccination is called Gardasil and Cervarix. And it is given 3 doses, or the recommendation is that 3 doses should be given. The first dose is given within the first month and the second month you will be given the next dose and six months from the first dose then you will be given the third dose. That is how they do it. (Group 1, participant 9)
	(c) Infectious status	“Anybody who is tested and is negative can be vaccinated” (Group 2, participant 9) “I don’t understand what you are saying because you can’t just vaccinate someone without doing the pap smear first,. how are you going to make sure that the person is positive or negative. They need to be tested first before the vaccine and if they are positive we don’t give them the vaccine” (Group 1, participant 8).
	(d) Age eligibility (e) Vaccine importance	“I support the initial concept that people could be vaccinated at birth, in that way once you are born and you have immunity to the HPV. At birth, you have the vaccination to protect.” (Group 2, participant 4) “So teenagers have become sexually active, so if we are to vaccinate, it’s better to start from the secondary schools, even possibly the junior secondary schools here.” (Group 3, participant 1) “It’s important because it protects for a lifetime. If you are being vaccinated with three doses, it means you are protected from the HPV virus for a lifetime.” (Group 1, participant 2)“When you are being infected by this virus, the likelihood of you getting cancer is high. So it is very important to get vaccinated to stay away from cancer and all the others.” (Group 3, participant 4)
3. Initiation of communication
Education & Counseling
	(a) Hospital visit	“… those of us at the family planning center, when someone comes there, we normally do education, health education for them. … We talk about it as the virus, how it occurs and how it causes cervical cancer and then the pap smear as well.” (Group 1, participant 9).
	(b) Positive status	“The pap smear will let the person go and get the vaccination, because if the person is sexually active then they have to be tested before the vaccine. If they tested positive, they don’t get vaccination” (Group 1, participant 9).
Limited Vaccine Comm.
	(c) Neglect	“It’s one of the conditions that we said it is neglected, we don’t focus on it. Because we don’t have data and I don’t know what it is public health importance to authority. So once we don’t have an interest in that aspect even education and awareness may not be done.” (Group 2, participant 6) “Sometimes the problem that we are facing in the family planning now, people come in to do the pap smear but we don’t have the kits for seven months to almost a year, we don’t have the kits. Look at this. We don’t have the kits for them to test whether they are negative or positive before they go for the vaccine.” (Group 1, participant 9)
	(d) Competing priorities	“It is not our priority. We have some diseases like malaria, HIV, TB that we focus on that. Like Ebola, those that can cause pandemic or epidemic, the rest but for HPV it’s not our priority so we even don’t talk about it.” (Group 2 participant 7)
	(e) No data	“… if HPV is the lead contributory factor or is the only way one can get Cervical cancer, then our data is not correct. …, we are using the ICD (International Classification of Disease) data to code all the ailments that are reported here. So, if the doctors catering for such cases lump everything up and write CL of the service, without giving us all the other contributing diagnosis or ailments …, then we also not report on HPV. So, data in African and Ghana for that matter is something.” (Group 2, participant 5). “HPV I would say we don’t know much or we don’t have much data on it. If we do it’s silent. It’s not like malaria or tuberculosis whereby we can just click and get it.” (Group 1, participant 1)
	(f) Acute illness	“I think it’s because of the clinical situation. You know when the patients come your aim is to address the condition they present with; so if it doesn’t go in that direction, it’s not likely that you bring that topic up.” (Group 3, participant 2).
4. Participatory dialogue
Advantages
	(a) Build immune system	“Your antibodies will be developed, and your immune system will be stronger to fight the virus.” (Group 2, participant 5)
	(b) Prevention	“From a social scientist's point of view, the vaccination, as you take it, it prevents the disease rather than to wait for you to acquire the disease and then start treatment which is expensive.” (Group 1, participant 1) “To protect you from a disease that is preventable. It is also to, you know, it protects the community depending on the number of people who are vaccinated, even if someone comes into the system with the disease.” (Group 3, participant 2)
Disadvantages
	(c) Stigma	You see, the stigma that comes with it, especially the things that- there is this notion that once you go for this vaccine it means that you have the intention of either engaging in sexual activities or already doing so, people stay away because of the stigma associated with it.” (Group 3, participant 10) “Some females wouldn’t want their peers to know they are sexually active or they want to become sexually active. So in order not to let them know, they wouldn’t even go for it in the first place.” (Group 3, participant 3)
	(d) Religious objection	“Talking about churches, most churches will not encourage pre-marital sex. So they may see it as a means of promoting immorality when you vaccinate adolescents and teenagers, they are seeing you as amoral and they will not support it because of that.” (Group 3, participant 4).
	(e) Discomfort/pain with injection	“Every vaccine has its own way of making people uncomfortable or has its own side effects. It may make you feel weak.” (Group 2, participant 1) “Not all patients like to be injected, in fact, the majority of patients would avoid injections as much as possible … after the vaccination, it comes with so much pain that the arm will hurt for quite a number of days so discomfort, it will deter people from getting vaccinated.” (Group 3, participant 1)
5. Behavioral Confidence	(a) Predisposing	“We need to have access to information, how safe the drug is, the studies that have been done to evaluate the safety and efficacy aspect of the drugs to convince myself that it is safe and efficacious, that is when I will give it to others. So, the information about safety and side effects should be transparent.” (Group 2, participant 4)
	(b) Enabling	“The parent consent will make me feel confident. The involvement of the parent in the child’s health will give me the confidence to give HPV vaccination.” (Group 2, participant 2).
		“I thinks it should be encouraged from the national level where there will be education from the national level about the seriousness of the HPV and its health implications. Like HIV people are aware of its health implications because of the involvement of national leaders and awareness created by the national media. So, if we show on the TV the problem associated with HPV and the problem with cancer, I think people will become aware. In most cases, people died of cervical cancer and they are not aware, and the family member will be saying that the person was just sick and went to the hospital and just died but if we create awareness, people will see the seriousness of the problems.” (Group 2, participant 3)
	(c) Reinforcing	“And, other people have come for the vaccine and it has worked very well for them. So that will give much confidence in delivering any information about the vaccines to them.” (Group 2, participant 3) “Everything is based on evidence and I can cite an issue whereby there is no evidence that the vaccine gives complications or anything. So it is based on evidence. Even though many of them have been administered, you haven't heard of any complications coming out of that so that confidence level is high and the vaccine is effective.” (Group 1, participant 1)
6. Physical Environment	(a) Structural	“The availability of the vaccines. If I educate somebody and if the vaccine is not there what are we going to do? So, the vaccines should be available at reasonable prices before we even talk about education. (Group 2, participant 2) “When you are able to get to these points of vaccination, you need to at least travel from one point to the other. Your means of transport one and also the available roads and then the other means to get to where you are going to do the vaccination is important because some people may be hindered because they have to travel a long dusty road and by the end of the day they will be- their clothes will be filled with dust and they will be tired; so they will not be encouraged to even attend even if you were to organize a vaccination.” (Group 3, participant 7)
	(b) Monetary	“I want to look at if from that the government will buy the vaccines and make it available to the ordinary Ghanaians. The government can buy it, reduce the price or subsidize the price to let’s say 5 Ghana Cedis,[less than $1.00 equivalent] that will help others to go for the vaccinations.Simply put, there is no widespread, systematic, publicly available HPV vaccination program in Ghana to increase vaccination rates” (Group 2, participant 5).
	(c) Administrative	“We need Facilities, personnel, monetary incentives, education and refresher courses. We need the human personnel before you can initiate any move. Without human personnel, you cannot build the facilities and the whatever. If you don’t have human personnel, it would be very difficult to champion any course.” (Group 1, participant 9)
7. Social Environment	(a) Informational and tangible support	“We need support in the community and parents, we need ethical clearance (parental approval). … I would say the social support that we need is parental contribution or support. And if we are doing it in the community, we need to get one or 2 opinion leaders and explain for them to understand the issue. So if we receive support from the community leaders it will help boost our morale to continue to offer education but before we receive those opinion leaders' support they need to understand what the vaccination is all about. If community leaders provide a platform by mobilizing the people for us to provide education to the masses.” (Group 1, participant 1)
		“In our communities, we hold the churches in high esteem so to involve them to be able to advocate for the vaccine would be an advantage for the program.” (Group 3, participant 7).
8. Sustenance		“After I have given the injection, I will take the parents' phone number so that …, I will give them a call, … to remind them that their child is due for their next injection… give them a small book to write the next date for injection in it.” (Group 1, participant 9).