Table 2.

Major themes and representative quotes

	Theme	Group (%)	Representative Quotes	P/E/R^a Factors
Patient Barriers	Link to sexual activity	Pediatricians (89%) Parents (71%) Nurses (100%) Stakeholders (75%) Ped Survey (77%)	“Maybe, parents who, I really don’t know how you say it, they may not want their children to have it because they may say, “Well, my child’s not sexually active.” I know that nowadays they are. They’re starting young. I hope my son, I hate to think about that, but a lot of parents, they are, in denial about their children being sexually active.” – 41, female, parent “…then we have stronger ties to religion in the south and especially in Alabama, which means the discussion around sex is way more taboo” – 33, male, stakeholder	Predisposing
	Misinformation – from internet or peers	Pediatricians (78%) Parents (71%) Nurses (100%)	“Then the stuff on Facebook. The untrue articles and that stuff. I even had a mom tell me one day, the same one that told me that it caused her friend’s child to have arthritis, she said, “Well, we’ve all got to die some way.” I was thinking, “Well why did you get any of those other vaccines?” Just untrue stuff. It’s so hard to disprove or talk them into. People just believe everything they read.” – 30, female, nurse	Reinforcing
	Lack of knowledge	Pediatricians (67%) Parents (100%) Nurses (83%) Ped Survey (89%)	“The other that I do not feel like I’m ready to even remotely make a decision is about my son. There definitely needs to be more material out there for that. If that is something that you feel is extremely important for males to receive, that information has got to get out there. Because I had no clue – no clue whatsoever that that was even need and why it was needed.” – 36, female, parent	Predisposing
	Concern about vaccine safety	Parents (71%) Nurses (67%) Ped Survey (83%)	“Well, I’m terrified if my daughter has the vaccination that it’s going to be my fault if something happens to her. I could prevent that from happening by not having her vaccinated. Most people have HPV anyway unless you only have one sexual partner. I don’t know. I just go back and forth with it.” – 41, female, parent	Predisposing
	Skeptical parents	Parents (71%) Nurses (67%)	“Just saying I would, I would have to give it a lot more thought with it being such a new vaccine. It’s just, to me, it’s kind of like when there was all that uproar about MMR and it causing, could it be causing autism. I never questioned that because I feel like MMR was, that vaccine has been around since I was a kid.” – 36, female, parent	Predisposing
	Infrequent adolescent visits	Pediatricians (67%)	“Then we see the teenagers as they need. We try to get them in for their physicals, but iťs difficult sometimes to get them in. The college students, they come in on an as-needed basis when they're sick or need an excuse for an exam they missed” – 74, male, MD “Well, adolescents I would say often are not coming in as often as little ones so they are not in the office as often” – 45, female, MD	Enabling
Provider Barriers	Time	Pediatricians (78%) Stakeholders (75%)	“But I also have, like all of us have a limited time to address problems and you have got to – you have to choose your battles. And for me to choose the battle of having a long discussion about this with someone who is against it is frankly a massive waste of my time that I’m not going to do.” – 63, male, MD	Enabling
	Weak provider recommendation	Stakeholders (75%)	“It’s provider barrier, totally. I’ve heard it from the doctors myself. My own children’s, they’re adults now, but I still interact with her at the AAP and she basically says she asks them do you want school required vaccines or do you want CDC recommended vaccines today?” – 54, female, stakeholder	Enabling/Predisposing
	Clinic logistics	Nurses (83%)	“And then, our schedule is not even open six months in advance sometimes. So that’s what makes it even harder. You have to rely more on the mom making a note in her calendar.” – 26, female, nurse	Enabling
	Provider uncomfortable discussing sex	Stakeholders (75%)	“I think iťs just all of the providers afraid of what parents may ask, not that the parents actually ask questions.” – 40, female, stakeholder	Predisposing
System Barriers	Insurance/finan cial	Pediatricians (67%) Parents (71%) Stakeholders (75%)	“I mean it’s an obscenely priced product and the reimbursement – I have a friend that’s in the tractor business and we were playing golf one day and I told him what our margin was on vaccines and he just laughed and he said, “Good thing I don’t do that in the tractor business, we’d be broke”” – 63, male, MD “Well, one for me is I’m not sure that insurance covers this. And that would be a concern.” – 36, female, parent “There’s been some confusion about if you have private insurance whether it’s covered. Different practices may or may not accept Medicaid and they’re charging Blue Cross/Blue Shield patients for the full cost of the vaccination even if they’re participating I think in the VFC program.” 40, female, stakeholder	Enabling
System Barriers	Lack of access to vaccine provider	Stakeholders (100%)	“we have a large number of counties where the only place you can get the shot is the county health department. There are a couple of country health departments that only do shots three hours day. Now all of the sudden the burden for a parent to get this is incredibly high. It’s already something they don’t want to do. Now we’ve made a lot of barriers to them actually getting it” – 33, male, stakeholder “We mostly work with family medicine because we don’t have a lot of pediatricians in our service area so it’s from the family medicine side…We have pediatricians in three out of thirteen counties.” – 40, female, stakeholder	Enabling
Patient Opportunities	Patient education	Pediatricians (78%) Parents (100%) Nurses (100%) Stakeholders (100%)	“Just education. Education across the board. A lot of patients do not know why they need it. They do not understand it. There has been so many bad raps against vaccines and autism. They do not want to get anything more than what they have to give.” – 46, female, nurse “It’s not even just education, we educate about it, but providing the right information in the right form to the particular patient we are talking with. There are some patients I can say, “It prevents certain types of cervical cancer,” and they say, “Oh okay, yeah.” Then you tell other people that and they don’t know what a cervix is. It means nothing to them that it prevents cervical cancer. Better tailoring the education, better tailored the demographic you’re dealing with.” – 34, female, nurse	Predisposing
	Message of prevention	Pediatricians (100%) Parents (100%)	“And because, if you think about it, it makes sense. We are all about prevention. If I can prevent with a shot, why in the world not do the shot?” – 62, male, MD	Predisposing
	Social media/online	Parents (71%) Stakeholders (75%) Nurses (67%)	“I think we should utilize social media ads to help fight some of the antivax stuff.” – 33, male, stakeholder “I click on a lot of things at my doctor’s office. They post things on Facebook and I go to a lot of the things that they specifically post.” – 36, female, parent	Reinforcing
Provider Opportunities	Provider incentives/metrics	Pediatricians (67%) Stakeholders (100%)	“…provider level feedback reports. So I want to be able to, as part of, again, one of those benefits that you are as an ImmPRINT participating provider, here is your immunization rates as it relates to people that are in your community and as it relates to benchmarks against the state.” – 33, male, stakeholder “Because if you know, and as physicians we’re very competitive. If you knew that your vaccination rates were so much lower than someone else’s, it may help you strive.” – 56, female, stakeholder	Enabling
	Staff/provider training or education	Pediatricians (100%) Nurses (83%) Stakeholders (100%)	“I mean, seriously. Come out and say here are there real numbers. Here is really how we are decreasing cervical cancer, here is really how we are decreasing the number of abnormal Pap smears, here are the real numbers on the VAERS side-effect report. You know” – 41, female, MD “… sometimes we don’t know what we don’t know, so ask questions during a lunch-and-learn and engage the nurses and just wait for us to ask questions because we might not know that we need to ask questions.” – 32, female, nurse “So, again, the key would be to find a way in which to reach those individuals on their grounds or their territory. Meaning can we email you? How can we provide information that would help you improve the quality of care that you’re delivering, i.e. vaccinating more?” – 56, female, stakeholder	Predisposing/Enabling
	Utilize nurses	Pediatricians (100%) Nurses (100%)	“When they (nurses) are in the room, that’s usually when the first time it comes up, how many shots am I getting today? That’s when the nurse will sometimes tell them if they know, if they anticipate knowing I’m going to say…but that would be good for them to bring up or just say, hey I noticed you haven’t had this.” – 54, female, nurse	Enabling
	Utilize technology	Pediatricians (78%) Nurses (83%)	“-yeah, just pretty much with computer reminders, scheduling, if our templates open a little bit sooner we can probably go ahead and get those scheduled and get them set up to have those automated reminders. That will probably help.” – 32, female, nurse	Enabling
	Reminder system	Pediatricians (78%) Parents (86%)	“You forget. There’s so much other stuff going on, parents forget. Send them a reminder, send them a text, call them” – 41, female, parent	Enabling
	Provider counseling	Parents (100%)	“I’d rather him (the doctor) suggest and talk to me about it than to dictate to me, “You need to do this, this, and this,” without any further discussion about it.” – 41, female, parent “Sometimes their language is just too medical, too big, and too broad. It’s easier to kind of break it down and to personalize it. They have so much knowledge, but not everything applies. Does that make sense?” – 28, female, parent	Predisposing
	Doctors are trustworthy	Parents (86%) Nurses (67%)	“Because like I said before, I know that doctor – that one specific doctor. I know her personally, I trust her. Yeah, things like that from reliable sources, known sources” – 36, female, parent	Predisposing/Reinforcing
System Opportunities	Promote or educate in schools	Pediatricians (67%) Parents (71%) Nurses (67%) Stakeholders (75%)	“For the kids, I think to educate kids in a school setting might not be a bad place. Not to try and sway them, but this is the information you should talk to your parents about it. That might be one way to provide the education that you’re going to get a large group in one setting…It’s not like we see a ton of teenagers every day. School setting might be a good place for that.” – 29, female, nurse “As far as like the kids who maybe slip through system, that are not actively being followed by a pediatrician or seeing care every year for the physicals. I guess, you know, if they are actively enrolled in school, I mean maybe we should, you know, promote some of that through school.” – 36, female, parent	Enabling
	“Blue card” – policy or mandate	Pediatricians (89%) Nurses (67%)	“The first dose we generally get them because they have to come for the 11-year-old check-up for the TDAP. That’s the way we get them initially.” – 29, female, nurse	Enabling
	Provide or promote in community organizations	Pediatricians (67%) Stakeholders (100%)	“Yeah, I do believe, especially in the black community, if anything is brought to the church, I think the people would be more receptive to it” – 55, female, parent	Enabling

^a.

P/E/R: Predisposing/Enabling/Reinforcing

Data collected in Alabama from 2015 to 2017