Abstract: Clinician Stakeholder Perspectives on HPV Vaccine Uptake Across Indiana Counties: A Qualitative Diffusion of Innovation Study
HPV vaccination rates remain sub-optimal and there is substantial geographic variability in HPV vaccination across Indiana. Building on this quantitative epidemiological data, Diffusion of Innovation (DOI) provides a framework for exploring the qualitative perspectives of key stakeholders in high and low HPV vaccination areas to understand reasons for vaccine acceptance and uptake. We obtained a state-wide list of vaccine clinic coordinators, split the sample into high, middle, and low county HPV vaccination rates, and then recruited participant stakeholders from high counties (HCs; n=22; avg. HPV vaccination rate=57.6%) and low counties (LCs; n=23; avg.=27%) to participate in telephone interviews. Interview questions explored reasons stakeholders believed their counties had high or low vaccination rates, approaches used to increase rates, and specific strategies used for girls and boys. Using DOI as a framework, we analyzed the transcripts using Braun & Clarke’s thematic analysis procedure. We engaged in a recursive process of first examining the data as a whole, and then moved to examining data from the high and low counties for explicit comparison purposes. We developed two major themes related to high and low rates of HPV vaccination adoption: parent-provider communication issues and multi-level system issues. The first major theme focused on the nuances of parent-provider communication about HPV vaccination. While both HCs and LCs indicated using educational materials to increase parental knowledge about HPV vaccination, stakeholders in LCs reported parental misinformation as an insurmountable obstacle to persuasion. Also, while stakeholders in both HCs and LCs were passionate about helping patients receive the vaccine, LCs expressed more frustration with barriers. Not surprisingly, HCs saw parents as partners in the decision-making process versus LCs who viewed parents as obstacles. Two subthemes around vaccine presentation emerged as well. HCs reported presenting the vaccine as “due,” while most LCs did not. Further, in contrast to LCs, HCs reported using targeted strategies to ensure parents saw the vaccine as compatible with protecting both sexes. The second major theme was multi-level system issues (e.g., clinic, school, community, and county) affecting HPV vaccine uptake. HCs reflected on the importance of professional development for all office staff, outreach programs with the surrounding community, and a positive relationship with the school system. In contrast, these elements were not addressed in a meaningful way by LCs. LCs did stress several structural barriers that negatively impacted HPV vaccination rates (e.g. difficulty scheduling appointments, insurance/reimbursement issues, etc.); HCs did not mention these as barriers. In sum, HCs saw the larger social system as facilitating diffusion of the HPV vaccine, while LCs identified aspects of the social system as impeding diffusion. This study revealed important differences in communication about, and perceptions of, HPV vaccination barriers and facilitators among stakeholders in LCs and HCs in Indiana. DOI provided a useful framework for uncovering these differences that exist at within the clinical encounter and the larger social system. Moving forward, the successful strategies used in HCs could be used within LCs in order to increase vaccination rates and reduce geographic variability in HPV vaccination.