A qualitative descriptive study of providers' perspectives on human papillomavirus vaccine administration among Latino/a adolescents in South Texas clinics: barriers and facilitators - BMC Public Health - BMC Public Health
Study participants (doctors and nurses) described how they recommended vaccinations to their patients during clinic visits and then had either their nurse or medical assistant administer the vaccine(s) after the visit. A summary of providers' perceptions of HPV administration facilitators and barriers discussed in this section are presented in Table 2. Key facilitators included parental acceptance/motivation for vaccinating their children, provider motivation of parents, policy (e.g., free, low-cost vaccination and obligatory reporting, and vaccine schedule), and implementing evidence-based practices as facilitators. Other identified barriers included lack of knowledge regarding the HPV vaccine, misinformation from media promoting anti-vaccination, fears related to children engaging in sexual activity, concerns about potential side effects of the vaccine, lack of transportation because of living in remote rural areas, lack of clinic reimbursement for providing the vaccine, and lack of vaccine affordability for patients without insurance coverage.
Perceptions of parental/patient factors as facilitators
Providers identified both parental motivation and receptivity to provider recommendation as facilitators of HPV immunization uptake. Dr. Cruz noted that in many cases parental buy-in was a given: "I don't have any difficulty for them to have the vaccine. I don't even need to tell…[them] it is important and have it done. They will voluntarily go and have it." Several providers had observed that a parent's family history of cancer or personal experience with HPV or cervical cancer as a motivator for vaccinating their child. For example, Dr. Ellis noted "[t] here are some families that have cancer that is predominant in their families. Those are the ones that…ask for the HPV vaccine, even before I even bring it up. They're the ones that are all over it and…complete the three-dose series…." Dr. Alonso commented, "The [parents] that want it, it's usually because they have a personal or close story about somebody with cervical cancer or something HPV-related. They're actually very eager and actually request it."
Some providers noted having encountered parents who were "very receptive to recommendations by the healthcare providers" and readily took into consideration the provider recommendation before deciding to vaccinate. The following examples illustrate how several participants associated the importance of having good parental communication skills with the need to encourage parents to consider HPV vaccination: "I think it's more confidence and more listening to them carefully and answering them carefully (Dr. Lewis)." "…It's a matter of talking to them in terms that they can understand…. (Dr. Alvaro)." "[I]t depends…how well you explain it, how well you communicate with the parents and any myths that they may have (Nurse Rose)." Dr. Ellis also used the effective strategy of providing a motivating cancer prevention message: "What helps me [is] when I mention the prevention of cervical cancer, and tell them it's the third leading cause of cancer world-wide - leaning towards the cancer prevention really does help convince a family decide to go through with [the] HPV [vaccine]…".
Perceptions of economic and organizational facilitators
The majority of providers reported that the HPV vaccine is available for free or low cost to their patients who qualify for the Texas Vaccines for Children program. The state covers the cost of the vaccine for clinics "because the vaccines are provided by the government and we don't charge for the vaccines," and patients who provide proof they qualify for the program can receive the vaccine free of charge. Nurse Rose noted there might be additional costs to patients: "This is a federal qualified clinic. We don't charge, we only charge a minimum amount for the visit ($10). We don't charge for the immunizations." However, she noted barriers related to other potential costs: "Financial, maybe due to lack of transportation but not for the cost of immunization."
Dr. Alonso noted that required guidelines associated with statewide immunization funding was a motivating factor operating at the institutional level: "…The thing that's made it easier is more of [what] we're graded on…so unfortunately, it comes down to money. So, if we're being graded on it, that we have to implement these guidelines to at least offer the vaccine, if not give it." Among the providers interviewed, there was general consensus that both the state vaccination requirements and the availability of funding to cover the cost of vaccines facilitated the implementation of HPV vaccine guidelines within their clinic practices.
Other facilitators to expanding HPV vaccine coverage included state-mandated vaccine requirements for 11 to 12-year-old children. Dr. Morrison described the situation as follows:
So for sure, I would put at the top of the list the fact that our population follows [the vaccine] requirement almost blindly. I don't know if that's the inherent fear that they have of the people in power. But if a school give[s] them a yellow slip to go to the pediatrician, they will come."
Nurse Rose aptly noted, "…whenever you have immunizations that are required by the school system and they come at the same time, it's easy for them to just get it [HPV vaccine] at the same time.
At the organizational level, factors facilitating HPV vaccine uptake included clinic practices ranging from streamlined scheduling to parent-friendly operating hours: "…[T]hey can come in after school. We're available till 5:00 for vaccines and we do have even the night clinic available. If they need to, they could even come back in our evening clinic if they wanted to (Dr. Norman)." Other organizational facilitators included dissemination of patient reminders and standing orders:
I think that in this particular clinic we have a good scheduling department, so when they leave that initial visit with the first series then they do really call the patients at two months just to make sure that they come in for the visit. We also don't actually schedule them with a doctor for the completion of the series. They just come in for a nurse visit. They just come in and the nurses will get the immunizations ready and they immunize the child. – Dr. Cascabel
Perceived parental/patient barriers
Providers identified parental/patient barriers such as knowledge deficits; exposure to misinformation; existing health beliefs such as fear of their child engaging in sexual activity and concerns about potential side effects of the vaccine; lack of transportation, and cost of vaccination.
Parental knowledge deficits
Providers identified a number of parental barriers, ranging from lack of knowledge and understanding of basic information regarding the HPV vaccine, to structural and economic barriers. Limited parental educational levels, preconceived ideas, and exposure to misinformation were factors providers identified as contributing to parental lack of knowledge regarding not only the existence of the clinic and the HPV vaccine itself. Providers acknowledged a generalized lack of awareness and knowledge of the HPV vaccine. An example of these providers' perceptions of knowledge barriers included Dr. Alonso's observation: "Most people just don't know about the vaccine, or if they have, they have just heard one bad thing about it and don't really research it or ask more questions about it." Nurse Kristoff identified parental educational and cultural factors: "…I think the lack of education, or either the lack of understanding. I know some of our patients have limited education levels, and they have preconceived ideas or cultural barriers." She further reflected on her interactions with parents, noting they often want to have time to make a decision, and the inherent risks of allowing parents to take this time: "And even in trying to talk to some of them, they want to think about it; and then, of course, if you give them too much time to lapse between the visit and thinking about it, they don't come back."
A few providers associated parental exposure to misinformation from the media (e.g., Spanish-language television, Internet) as a concern. Dr. Morrison stated, "a lot of misinformation ….From my understanding...[it] is the Spanish media…had a lot of information about this being [related to] the sexual stuff…" Regarding parents seeking information on the Internet, Dr. Alonso described his experience with resistance from more highly educated parents armed with misinformation:
…We actually find a bigger resistance to the vaccine in our insured population, because they're looking more at who-knows-what websites that have said "this vaccine does whatever to you," so our bigger problem [is] giving the vaccines…to…our educated population. [They] refuse it because they're spending too much time on the internet.
Parental concerns about sexual activity and negative consequences
Providers also discussed the ways in which parents' concerns of the HPV vaccination contributing to or facilitating a child's engagement in sexual activity: "you are giving them the blessings to go have sex, which is the perception, the fear." Nurse Kristoff reflected on the difference between how parents and teens may view the HPV vaccine:
…[A]s a parent, you don't want to think of your 11-year-old being sexually active. As a mom you think, okay, if you give them this shot, is that in their mind then a rite of passage to, 'Oh, now I'm free from this sexually transmitted disease, so now it's okay to have sex.'?
The association of the HPV vaccination with birth control was another parental concern that providers encountered. Dr. Alonso stated, "The ones [parents] that absolutely refuse it, there seems to be the misconception that getting the vaccine – they think of it as birth control, so it's like if they [adolescents] get the vaccine, that means they can go and have sex." Dr. Avis noted a tendency for some parents to equate women getting cervical cancer as "pay back" for having been being promiscuous as adolescents: "…because [parents] hear that [HPV vaccine] might make them more promiscuous and they don't want to protect them…It's this attitude that…if they end up getting cervical cancer, well, for being promiscuous, they kind of deserve it, which is scary." Parents who believed their children were not susceptible to HPV-related diseases also concerned providers: "…[Some] Moms and Dads feel like their daughters are not sexually active and so they don't really need to give the vaccine and it can wait. And so, I think just postponing it is a big issue…(Nurse Messias)" Several providers also identified some parents' concerns about possible side effects from the HPV vaccine as a potential barrier:
…I think Hispanics are fearful of the unknown. They're not sure of how their child is going to respond to the vaccine, if the vaccine is harmful to their child. They actually want to wait till their child is 18…to make that decision. That's what I've encountered a lot…some are just stuck on: "My child could be permanently disabled or die from this vaccine."
While Dr. Morrison related her experience: "And it is a painful vaccine according to patients…We've had a couple of adolescent girls, we've had one faint and another one get dizzy…."
Perceived financial and transportation barriers
Financial concerns, whether actual or perceived, also created barriers to parents seeking HPV vaccinations for their adolescent children. Dr. Morrison reported increasing parental concerns regarding paying for vaccine among the insured: "Yeah, that's part of parental concerns: 'How much is it gonna cost?' And we tell them – well, my understanding is you can no longer get 'em under Vaccine for Children if they have insurance. So that's a big one too." Given the low socio-economic status of the local community, providers recognized the cost of the vaccine as a deterrent for the local community:
We have a very low-income community here, and I think the main reason why we have a few of these people coming in here is because of the cost. Once they know the cost, you know, they usually decline [the] vaccination. Not because they don't want to, but because of the cost of the vaccine. (Dr. Luna)
Dr. Avis noted that very few of her college-age patients have insurance coverage and therefore were not able to afford the vaccine:
They are very few that have insurance. The majority - once you turn 18, you get bumped off of Medicaid, and so the kids don't have anything….They're left in limbo...I would say that it is difficult, because we charge for it. I think I would be able to talk a lot more students into getting it if it was free…I'm pretty sure my vaccination rates would be a hell of a lot better."
Limited access to transportation, particularly among those living in more remote locations, was another barrier to completing HPV vaccination. Providers noted that the majority of their Latino/a patients live in "a remote area, rural area, [and] they depend on transportation." Nurse Rose attributed the lack of transportation to the high rate of no-shows for immunization visits among her Latino/a patients: "….I look at my schedule every single day and I say, okay, I have about five or seven of the immunizations coming in. The trouble that I see is the [lack of] transportation because they only show maybe two or three."
Perceptions of policy level clinic barriers
Providers identified two policy-level barriers to HPV vaccine uptake. The first is that HPV is a recommended, but not required, vaccine. Providers aptly noted that required immunizations are associated with more severe consequences, and that "when you get to the HPV and the nurse is writing in parentheses "recommended," then that becomes a whole different issue." Dr. Lewis explained how this plays out in his practice:
Parents understand there are fearful consequences associated with not "following the recommendation that the school is asking them to follow. It's very simple. [The HPV vaccine] is not compulsory. That's it. Nobody understands the vaccine. If it's compulsory, you give it for the school, let's start. If it's not compulsory, I'll think about it and I'll come back, and they don't come back. It's a compulsion by the school. That's what makes the other vaccines perfect.
Several providers also identified specific insurance-related barriers. These included insurance plans with required patient deductibles for the HPV vaccine, or challenges related to qualifying parents/children for federal programs to cover the vaccination cost. Dr. Morrison noted the challenges even insured patients face:
They don't make it clear to parents…so sometimes…if they have insurance, we're not able to qualify them for the federal program. So that, I think, is a barrier for insured patients. They're always concerned about, "How is this getting paid? How much am I gonna have to pay?" That type thing.
Providers also encountered several organizational hassles, ranging from not having the HPV vaccine in stock to problems obtaining state reimbursement for the cost of the vaccines. At the institutional level, vaccine costs were a significant barrier:
…[I]f we're able to get it in a way that doesn't break the bank for us and insurances are gonna reimburse us and the state provides us without just a huge amount of hassle, then those are the only barriers that I can see… (Dr. Morrison)
According to Nurse Kristoff, not always having the vaccine in stock was a barrier for her patients, particularly those with transportation issues:
As long as we have the vaccines available, so no one has to wait for them, you know, be asked to come back, because I know that's a deterrent because we do live in rural Texas out here. So, coming back might mean a 35-minute drive.
Working at a practice that did not have the HPV on site, Nurse Messias reported all her patients had to be referred to the public health department. She noted both the extra work this created for her and the increased burden on the health department and the patients: …Generally, I think it's been left up to the health department to do it. I can't [provide the vaccine]…then, [to obtain the HPV immunization at] the health department, you have to call and make an appointment, and then you have to remember to go there and get your vaccine. So, I think it's pretty difficult.
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