Summary of Barriers

 Parents are not offered vaccination
  “I agree that I think the vaccine is a good idea so I would likely accept it if offered.”White father of 13-year-old, private practice
 Parents perceive vaccine as optional or unnecessary at that time
  “If we had said yes it would have been fine, if we had said no it would have been fine. Very optional.”–White mother of 12-year-old, private practice
  “[We didn’t vaccinate because] she was kind of low risk… in terms of sexually activity, that sort of thing.”–African-American mother of 14-year-old, public clinic
 Parents perceive that their providers discouraged vaccination
  “We changed doctors in this process and in fact I was rather distressed that [daughter's name]'s previous doctor recommended avoiding HPV vaccination for a couple of years which troubled me…. this would have been when she was twelve, thirteen, maybe even fourteen….He just recommended waiting for more studies and I thought the evidence was pretty conclusive already…. [We brought it up] multiple times and were fended off.”–White mother of a 15-year-old, private practice
  “I brought [HPV vaccination] up because I thought this was something that was being recommended and I had said, ‘Do you feel that my daughter should get it?’ And they felt, ‘No, she doesn’t really need to have it at this time.’ And I didn’t give it a second thought… I just kinda went with what the doctor said.”–White mother of a 13-year-old, private practice
 Parents want information about vaccine safety
  “I would like to see studies about what the risk level is more accurately, I understand things on the Internet can be a little bit sensationalist, you know ‘people did this and they died!’ it’s like yes, well people drive and they die too.“White mother of 13-year-old, private practice
  “I’d rather have my child die of cervical cancer then her die of me giving her a vaccine.”White mother of 16-year-old, private practice
  “I think it is important [to vaccinate] before they are sexually active. Like I said the more information I get in terms of the side effects will determine my ultimate decision.”–African-American mother of 14-year-old, public clinic
 Parents do not understand the reason to vaccinate at 11 to 12 years of age
  “I thought that it didn’t really make any difference as long as they had the three vaccines before their 20’s.”White mother of 12-year-old, private practice
  “It’s like blaming a kid before they even get a chance to do anything.”—African-American mother of 11-year-old, public clinic
 Providers are reluctant to give multiple shots at 1 visit
  “The 11 and 12 year olds I don’t usually recommend it then just because they’re getting other vaccines.”Pediatrician in private practice
  “So, we’re supposed to give it 11 but I tend to give it at 12 just because they’re getting two other shots at 11 and if there’s any real need to be giving it at 11 because they’re sexually active then we have a much bigger problem than HPV.”Pediatrician in private practice
 Providers introduce HPV vaccination at age 11 years but do not recommend it strongly
  “At [the 11 year old] visit generally I anticipate that they’re not going to do it and I talk to them about it.”Pediatrician in private practice
  “I’d honestly say it’s rare that I spend more than 20 seconds on it at 11… So few 11 year olds are physically mature to be sexually active that it’s, I find it’s almost sort of an awkward conversation.”Pediatrician in private practice
 Providers recommend vaccination based on their estimation of sexual activity
  “I rarely give it at 11 or 12. I most commonly give it in the like 8th, 8th to 10th grade range when sexual activity would put them at risk, rather than just an age. This is what I tell parents: it’s very different than other vaccines because you can quantify your risk by what you’re doing.”Pediatrician in private practice
  “I don't think about that consciously, but when I think about it unconsciously when I see this skinny little upper middle class kid here, with parents, and they talk and they're barely doing anything, and I'd be shocked if they became sexually active at a really young age and to bring all this up with the parents have 20 other things they want to talk about, it seems low down on the list.”Pediatrician in private practice
 Providers have limited experience with HPV disease and underestimate risk
  “I don’t get as scared of cervical cancer just because… the Pap test is another screening method. So the other things just feel more dramatic to me….. and it’s not like HPV is going to kill the boys.”Pediatrician in private practice
  “It probably is more likely that they would die from meningococcal meningitis then die from cervical cancer.”–Pediatrician in private practice
 Providers perceive HPV as more emotionally charged than other vaccines
  “If you have an 11-year-old boy and I'm supposed to talk about HPV, they're going to ask me why I'm recommending it, ‘Well when your son grows up, you know, he, it'll prevent him from giving cervical cancer to his partner and it'll prevent them from getting penile warts.’ This is a big discussion to have in front of a little 11-year-old, I don't even know what word they use for penis at 11.”Pediatrician in private practice
  “Eleven feels really young. That being said, there’s nothing to say it’s not safe that young but I do, I kind of understand why parents want to wait a couple years. But I don’t have… any specific safety concerns… I mean I’d probably do it [for my child]. Well I think I would almost do it more grade than age…. So, I would say 7th and 8th grade. I think that’s more appropriate.”Pediatrician in private practice
 Both providers and parents know they are often unaware of timing of sexual debut
  “It’s probably only maybe 20% of the sexually active teens their parents know.”Pediatrician in private practice
  “I feel like a lot of [teens], either say they’re not doing anything or they’re using condoms 100% of the time… but I’ve had a couple of pregnancies.”Nurse practitioner in private practice
  “I know how kids are, you know? For what it’s worth, I was sexually active from age 14 on and that was a long time ago.”–White father of a 14-year-old, public clinic
  “From what I understand the vaccine is safe, efficacious and I’d be a fool and also have amnesia to believe that high schoolers do not engage in unwise sexual practices at times.”–White father of a 12-year-old, private practice
 Delaying vaccination leads to nonvaccination
  “A lot of teenagers don’t think they need to come in because there are no real required shots after 11 and after 16 they feel kind of invincible.”Pediatrician in private practice
  “That’s an argument for doing it at 11 and 12 is that the child is more, the child’s schedule is more under the parent’s control at 11 and 12 than it is at 14, 15.”Pediatrician in private practice