We had 10 young adults, 20 parents, and 10 providers and public health professionals participating in the qualitative study. The young adults were 80% female and 20% male, 60% Black, and 40% White, 90% non-Hispanic and 10% Hispanic. The parents were 95% female and 5% male, 60% Black, 35% White, and 5% not specified. Adolescents were 53% female and 47% male, 42% were ages 9–12, 48% were ages 13–17 and 10% were 18 and over. Health system participants were 90% female, 10% male, 60% Black and 30% White and 10% not specified. More than half of participants identified as African American (60%), about a third identified as White (35%), and 5% of participants did not specify their race. Additional demographics of the sample are displayed in Table 3 and Table 4 and county representation in Supplemental Table 1.
Facilitators
There were facilitators for receiving the HPV vaccine identified at each of the three levels in the P3 Model. Facilitators at the patient level were having existing knowledge of HPV and the HPV vaccine, knowing the vaccine is safe, having knowledge on who can receive the vaccine and when, and having trusted individuals provide information about the HPV vaccine to their community. Facilitators at the provider level were the efficacy of the vaccine, framing of the HPV vaccine to patients, and revisiting the HPV vaccination with hesitant parents. Facilitators at the practice level were immunization reminders, patient registries, the use of social media (e.g., educational videos), and other health clinics who support the vaccine. Immunization reminders was the most mentioned strategy mentioned across participants, both for the patients and providers to remind patients about the vaccine. See Table 5 for more facilitator quotes for each level.
Patient level
At the patient level, participants (primarily parents of vaccinated children and young adults both vaccinated and unvaccinated) consistently referenced having existing knowledge of HPV as a facilitator to increase uptake in administering the HPV vaccine. In describing the vaccine, participants referenced a basic understanding of which cancers it can prevent, and ages at which adolescents can receive the vaccine. Parents and young adults understood the safety of the vaccine, which assisted in having positive attitudes towards the vaccine. One parent described: "I’m going to say it’s [HPV vaccine] some insurance for your child’s behaviors and actions later on in life, you know? Lots of insurance." (Participant 7, parent of vaccinated child). For young adults, they learned about the vaccine on social media, and through school. Enlisting trustworthy individuals to connect community members with information within the community serves as another facilitator for increasing HPV vaccine uptake. A director of a non-profit alluded to this: "I think once they are educated, you know, by a trusted voice, you know, whether that’s their physician or, you know, pastor or somebody, whoever that trusted voice is for them, I think they’re more likely to be acceptable to that." (Participant 39, health systems).
Provider level
At the provider level, parents of vaccinated children highlighted the approach their children’s providers took when discussion the HPV vaccine with them. The providers framed the vaccine as a preventative measure against other diseases. Providers often spoke of the efficacy the vaccine has against contracting and spreading sexually transmitted infections (STIs), and how those STIs may have more serious ramifications later in life. A parent described this perspective: "Just putting it out and putting the information out and let them stress that it is an STD just like any other STD. Of course, with repercussions in the future, and if you can prevent it, why not." (Participant 6, parent of vaccinated child).
In addition to framing the discussion, several education and messaging strategies were viewed as successful facilitators; these included patient visits at clinics, health departments, and utilizing community events to educate local community members. Some health system participants offered effective strategies such as revisiting the topic with hesitant parents and using information sheets to allow the parents to learn about the vaccine and its importance. One provider described their approach: "And I try to re-educate if they didn’t, just because a lot of it is that they kind of don’t know what HPV is. They’ve heard of the vaccine. They understand that it’s a vaccine, but I don’t think they really know what HPV is and why they should be concerned about it." (Participant 40, health systems). Parents of vaccinated children emphasized the use of brochures and pamphlets offered by providers as effective learning strategies. Some reflected on how this allowed for parents to take their time learning about the vaccine, and its benefits. Others viewed the brochure as a first step towards having a deeper conversation with the provider. Ultimately, parents thought brochures may bridge the gap for parents who do not know enough about the vaccine but want to learn more about it.
Practice level
At the practice level, immunization reminders sent to parents and young adults were seen as effective strategies by parents whose children were vaccinated and vaccinated young adults for patients to receive their HPV vaccine doses. Reminders included different formats depending on the health system, including phone calls and reminder cards. Health system participants also recognized different strategies to ensure patients returned for subsequent doses. These included the use of patient registries and highlighting those due for immunizations, as well as through the standardized Georgia Registry of Immunization Transactions and Services (GRITS), the statewide immunization information system. As one provider described their practice’s strategy:
"We have what’s called precall-recall, and so once a month we print out a list of our patients here that either they’re coming due for a set of immunizations they’ll be turning 11 in the next month. We’ll send out a letter that says your child will be due for immunizations on this day. We won't specifically say what immunization, but we’ll say they’re due for immunizations..." (Participant 9, health systems).
Community and Policy levels
At the community and policy levels, parents with vaccinated children and health system participants discussed techniques of using central and familiar locations like schools to engage in community outreach. Another one was to have champions within the community. One provider described: “I’d say insight into the community, definitely, to get the word out. Because if you don’t have somebody from the community that also buys in, then they’re not going to participate, not going to show up” (Participant 25, health systems nurse). For policy, health system participants mentioned vaccine programs, explaining: “I think we have a free program with HPV…We get them (adult patients) to sign something and then we can get it for free for people who are uninsured” (Participant 23, health systems provider).
Barriers
The barriers for receiving the HPV vaccine at each of the three levels in the P3 Model were the lack of information and dialogue around the HPV vaccine. At the patient level, the main barriers were a dearth of education on HPV and the HPV vaccine, misinformation, and stigma as is relates to STIs and sexual intercourse. At the provider level, a deficiency exists in direct provider-patient communication, including instances where providers fail to inform and recommend the HPV vaccine to their patients. At the practice level, there are a lack of systematic reminders for patient immunizations reminders, limited information, time, staff, and resources committed to the HPV vaccine (Table 6).
Patient level
At the patient level, a persistent theme among parents of both vaccinated and unvaccinated children in our study focused on a dearth of knowledge among parents and their communities about the importance of vaccinating their children against HPV. They highlighted how it is not a common topic to be discussed among parents with their children. One young adult described their experience as a child, “They’re (doctor) like, oh yeah, we now offer the HPV vaccine. Is it something you want to get? And my mom was like, eh, no, she doesn’t need that right now. And I was like, okay. I don’t really want a shot either, so it’s fine with me.” (Participant 17, unvaccinated young adult). Not only is it not being discussed, but parents described not knowing where to go to find more information about the vaccine. Health system participants also discussed how parents often did not have the necessary knowledge about the vaccine to effectively make decisions on behalf of their children. Stemming from this lack of education is the impact that misinformation has surrounding the efficacy, safety, and utility of the HPV vaccine. Two non-vaccinated young adults address misinformation, one stated, “…they’re [young adults] very hesitant about getting like even the COVID vaccine, just because, you know, they heard rumors, oh, it has this in it, it has that in it…” another stated, “They [young adults] look at social media and certain people may say this is what they do, this is what they don’t do, this is that. So I think actually with social media and peer pressure that conveys a lot of the youth.”
A director of a non-profit described, “I think all of the conspiracy theories that are out there now, and it’s even worse since COVID, nobody trusts, or a lot of people don’t trust public health messages anymore.” (Participant 12, health systems). In this context, the participant emphasizes the challenge of discussing the vaccine with parents and how a lack of trust in public health complicates messaging strategies.
Coupled with this misinformation was the resulting stigma of discussing HPV due to it being a STI. Vaccinated and unvaccinated young adults, both parents of vaccinated and unvaccinated children, and health system participants described how some parents may be reluctant to vaccinate their child, because they perceive it to indicate their child could be engaging in sex, or receiving the vaccine encourages the child to be sexually active. As one parent described, “Well, I think part of it is that since it is sexually transmitted, I think that a lot of parents don’t want to really delve into that thought that their kids are being sexually active or may be sexually active soon” (Participant 1, parent of vaccinated child). Particularly in southwest Georgia, sexual intercourse is stigmatized. As one provider described,
“I think the – I think stigma, because it is associated with sexual – a sexual nature. So, they kind of clam up like here in southwest Georgia, Bible belt, like it’s just kind of a – you know, you don’t speak of those things. Those are kind of taboo. Like everybody knows it’s occurring, but you don’t really want to I guess see your child doing – you know, doing things like that. So, I think it’s just the culture here” (Participant 15, health systems nurse).
By attempting to discuss a vaccine to prevent STIs, health system participants believed this may contradict many who view teenage sexual health education as only relevant through abstinence.
Provider level
At the provider level, parents of unvaccinated children and young adults (both vaccinated and unvaccinated) alluded to the dearth of direct communication with providers about the vaccine and revisiting the topic with their patients. Specifically, some parents described how their child’s doctor did not educate them on the reasons for getting the vaccine. As one parent described their experience with a doctor as:
"…they presented it, and asked did I want him to receive the vaccine, but at that time, I just had not had enough information on it personally, and with that, they did not give me any more information. And so, with that being said, you know, if my – if the doctor is not willing to provide more and give me more insight into it, any side effects, you know, statistics, and things of the sort, then you know, (laughs) yeah." (Participant 2, parent of unvaccinated child).
This parent highlighted how they may have been convinced had the doctor provided more details about the reason for vaccinating their child. Another parent with an unvaccinated child described providers not revisiting the HPV vaccine with them at later visits if the parent initially said “no.” Aligned with the lack of direct communication, providers were not informing and recommending the HPV vaccine to patients. As a director of a non-profit stated, “I think maybe lack of consistent recommendations. You know, they may get tied up in, you know, other bunch of check list of things that they’ve got to do and then may – it just may not be consistent throughout the flow…” (Participant 39, health systems). A parent also felt the providers need to be speaking more about the HPV vaccine in the exam room. One parent described, "I feel they should be more open and mention it in an exam. I do. I feel like they should. Not just have the poster up, like in the hallway. They still should mention it. The same way that they’re stressing the COVID vaccine, they should stress that vaccine in the same manner, I think." (Participant 35, parent of unvaccinated child). Here, the parent wished the approach to HPV and the HPV vaccine was similar to the COVID-19 vaccine in order for them to understand its importance during their child’s visits.
Practice level
At the practice level, participants described lack of systematic reminders for patient immunizations, limited time, resources, and staff allocated per patient, and lack of education in the clinic or medical offices. A parent of each a vaccinated and unvaccinated child referenced not receiving vaccine reminders. One of the parents stated: "Yeah. I think that like, for example, in my case, if there were an actual mailing that came to our house-...I would have seen it. I would have at least begun a conversation with my husband about it, and he was the one responsible for taking him to the pediatrician and getting it handled." (Participant 1, parent of vaccinated child). Although their child was vaccinated, the need for a mailed reminder would have facilitated discussions between the parents about vaccinating their child. Similarly, a young adult who received their first shot did not return for their second shot since they did not know when to return to the doctor’s office. Other barriers at the practice level include limited information, time, staff, and resources dedicated to the HPV vaccine. Both parents and health system participants mentioned time being a factor. One provider stated,
“Time would be one I would see, because with a lot of the things that we’re having to do now, you don’t’ have as much time to do the education as you would like to, and sometimes when you’re talking about sex and HPV, if it’s on a one to one basis, it’s hard to establish a rapport in five, ten minutes and get all the information that you need to get to them and then allow them to ask questions” (Participant 25, health system nurse).
As for the lack of resources, parents with a vaccinated child mentioned they have seen posters about measles, mumps, and rubella but not on the HPV vaccine and clinics not having enough of vaccines to distribute. A barrier widely mentioned across participants (parents, young adults unvaccinated, and health systems) were the differences between private practices and public health departments in rural communities. The differences between the two discussed were the patient-provider relationship and patient privacy differences. A parent explained:
“If you’re more familiar with the doctor you have more trust, and you’re more likely to take their advice. When you go to one of the local clinics, the convenient care clinics, it’s not a guarantee you’re going to get the same doctor. So, you may not be as comfortable having a certain conversation with one doctor as you would with a doctor that you’re used to seeing on a regular basis” (Participant 13, parent with a vaccinated child).
Another parent stated, “Private, is not private, and a lot of people may avoid going to the health department and would rather go to an outside pediatrician but don’t have the transportation to get there (Participant 6, parent with a vaccinated child). This parent explained health department layouts are openly structured and patients get called to a window to discuss their health information and people in the waiting room can hear those discussions, causing a lack of privacy for the patient, Similarly, a young adult unvaccinated also mentioned how privacy and courtesy of health professionals at certain clinics can be a barrier for patients. A lack of privacy is a concern at a patient level, while limited resources for transportation infrastructure affect the community at large.
Community and Policy levels
Several barriers at the community and policy level were mentioned by participants. At the community level the barriers include inadequate transportation, and lack of information within the community about HPV and the HPV vaccine and resources. A parent alluded to how important having a car is: “If I didn’t have a car, I probably wouldn’t even – I would barely go to the doctor if I had to use public transportation” (Participant 27, parent with an unvaccinated child). There is public transportation, but it takes more time and some unvaccinated young adults also stated how rural communities are spread out, which makes it challenging to travel to clinics that are out of their town and far away. A young adult described the lack of discussion around the vaccine in their community: “No, just that there is really not a lot of talks about it. I definitely think there needs to be more communication about it for sure” (Participant 17, unvaccinated young adult). At the policy level, the two main barriers participants mentioned were the financial barriers and lack of policies facilitating the uptake of the HPV vaccine. A provider described not being able to provide the vaccine to a minor without parental consent, “…hey, we can’t give them to you, because you’re not 18. We can give you, you know, reproductive care, but we cannot give you any vaccine without your parents’ permission” (Participant 15, health system nurse).