Table 3.

Factors Influencing HPV Vaccine Decision-Making and Exemplary Quotations

Themes	Exemplary Quotations
Parental influence and control over health decisions	“…family, it’s like a huge thing that informs my decision, my mom in particular because she’s the person that always takes me to the doctors. So if my mom approves of it, it’s kinda like it’s a go. If she’s hesitant, then it’s like, well, it’s Mom, then I’m hesitant too.” (Female vaccinated student) “…when I was under 18 obviously [my parents] had to come to the appointments with me … it’s just been me and my physician after like being 18.” (Male unvaccinated student) “[A few instances] it was more parent-driven of ‘My mom told me not to get it’ and when I get those patients, I just remind them: ‘1. Mom’s not here, 2. This is your body…your mom’s not the one that’s gonna get cervical cancer.’” (Women’s health physician)
Provider trust and strength of recommendation	“Usually I weigh the doctor’s, uh, advice more. Just because I feel like they have probably researched it more, but that’s not necessarily the case. But that’s the way I usually weigh it, yeah.” (Female unvaccinated student) “I think it’s definitely important for the doctor to bring it up. I don’t really know if there’s a standard place that people go to look at this stuff, so like I think where most of the information comes from is probably your doctor and like so, yeah it’d definitely be important for them to bring stuff up. Cause like I wouldn’t have known to take it otherwise.” (Male vaccinated student) “Basically if they haven’t had it…we recommend it for everybody, you know, under 26.” (Primary care physician)
Benefits of HPV vaccination for cancer prevention	“She [my provider] explained that it [the HPV vaccine] was to prevent cervical cancer and that we should get it before we’re sexually active…that was the main selling point. My mom heard ‘prevent cancer’ and was just like ‘Oh yeah, for sure.’” (Female vaccinated student) “You know this [HPV vaccine] is covering 90% of the cancer causing strains and so the likelihood of you getting all of those is not very high…so I try and encourage them that there would be the potential benefit despite them already being sexually active.” (Primary care physician)
Personal risk of HPV infection due to sexual activity	“…those factors came to my mind of whether or not I wanna be sexually active, the risks of getting cervical or anal cancer if one is sexually active, and the ease of just getting a vaccine and that there’s a vaccine for that.” (Male vaccinated student) “I wasn’t engaging in those [sexual] activities so I didn’t feel like I needed it…If I’m not putting myself at risk, I guess I don’t need it.” (Male unvaccinated student)
Influence of recommendations from professional bodies on perception of urgency and importance of HPV vaccination	“I got the HPV, but that was like later. So I think definitely that’s more optional than when you’re a child when you get all these boosters.” (Female vaccinated student) “Yeah because I was 21 and I think um like you should start getting your vaccine a little earlier than that so I didn’t want to like risk anything um so I just got it.” (Female vaccinated student)
Lack of awareness and knowledge of HPV vaccination	“I still feel like it’s kind of like a vaccination that I don’t feel has much education behind or much conversation or dialogue behind. Everyone hears about the flu vaccination and things like that, or keeping up on Hep B, but I haven’t heard of HPV ever in my life before I saw that like primary care provider or seen that poster on the wall and so I still feel like there’s a lot of miseducation on that or at least not enough information about that being spread around.” (Male vaccinated student)
Concerns about HPV vaccine safety and side effects	“If you want to take this shot, there’s 100 strains of HPV, 90% clear up on their own… It’s really not worth the risk of all these horrible side effects.” (Female unvaccinated student) “One person told me that a person they knew died from the vaccine and then there’s just an anti-vaccine component that’s either held by the student, but more times than not, it’s held by the parent.” (Primary care physician)
Logistical barriers to HPV vaccination receipt	“…with patients that are not on our [student health] plan, doesn’t help if they have insurance with their parents… it’s not covered here…especially now that the Gardasil 9 [costs] almost $200 a shot x 3, so obviously financially it’s not feasible for the most of them.” (Women’s health nurse practitioner) “…to make an appointment is just so far like into time sometimes I don’t know what my schedule is going to look like….if I were to have a free day like this upcoming week, like all the appointments for this upcoming week would be taken. You know?” (Male unvaccinated student) “…during the school year for people, it might be a little bit tough with trying to fit it into the right timeline.” (Male vaccinated student) “I try my best to say, ‘Hey, this the schedule.’ But if you, if you rag them [students] down to ‘You have to come in 1 or 2 months for the 2nd and 3rd one,’ they’ll be like ‘I don’t wanna start it.’ Because they can’t commit to that.” (Women’s health physician)
Health systemlevel factors influencing HPV vaccine delivery efforts	“A lot of that I think is physician um—it goes on the physician’s back. Just not having enough time in a visit where if a parent says [they] don’t want something, really not having the time to sit down and say, well let me explain to you why [you should get vaccinated].” (Women’s Health Physician) “There is a process of basically the clinician uses the whiteboard to communicate with us, put whatever orders are on there. We have to go in after we give the vaccines and chart it. That’s a standard thing, like you have to record the vaccination information and the note and all that and sign it off, so it’s pretty basic, standard thing, but some people may work a little bit different. Some may not use the whiteboard. They may come out and talk to us physically.” (Medical assistant) “There’s an immunization tree where you can just click on it and all the immunizations pop up, but that is populated only if the immunizations are entered manually…the MA’s would re-enter mainly the those mandated vaccinations and many times you know they leave out the HPV vaccine because it’s really not required for to for them to start [school]…” (Women’s health nurse practitioner)