Table 2 Themes and representative verbatim comments

Reasons for delay: children not at risk

"I don't think she need [HPV vaccine] at this time. I guess it's for girls that's having...sex...and I know my daughter and she's not into that right now."

Mother, age 44

"I think I would wait until she's a little bit older, 15 or 16. I just don't think they need it right now, at 13...it's young."

Mother, age 48

"Hopefully [Name] ain't having no sex...but you never know... Hopefully they won't be [sexually active] until they get good and grown. That's what we want but it might not happen."

Mother, age 51

"I don't think my children are at risk where they need to have it."

Mother, age 47

"[The HPV vaccine] is appropriate for when girls start dating, and things along those lines."

Mother, age 45

"I think there's some parents who think 'It's not my kid that's going to be having sex, so they don't need this at all.'"

Clinician, non -teaching practice

"[Name] is a perfect example...of a girl that you're pretty confident that at 14 is not sexually active...so you have a little bit of leeway."

Clinician, non-teaching practice

Reasons for delay: concerns about safety and efficacy

"I probably just want to know more about it and what the risks are...It's new to me...so I need more education on it."

Mother, age 51

"I'd like to know the side effects of it...how long they've been testing it."

Mother, age 30

"I still want to do a little more research...I've heard some pros and cons about it, and since we do have a longer time-line...that's why we're not doing it today."

Mother, age 43

"[Parents] had concerns about how long the vaccine's been out and the safety, and they wanted to have more time to think about it."

Clinician, urban teaching practice

Clinician hesitancy

"I don't push it the same way as... [other vaccines]."

Clinician, urban teaching practice

"I will say that I only push it so far...if I had a two-month old who is refusing...IPV or something like that, I might talk to them...I might take up much more time trying to convince them to do that, because I think that the nature of that illness is such that, you know there are devastating consequences...Now, HPV, the truth is that a significant portion of young women will get HPV, but a very large percentage of them will also clear HPV and not actually go on to have cervical cancer. So it's one of those vaccines where I think it's a good idea, but...I don't really twist their arm or anything."

Clinician, urban teaching practice

"She said she'd prefer to wait and get it later...Did she give any specific concerns about why she wants to wait ...No, and I didn't push her on that."

Clinician, non-teaching practice

"We probably don't press it as strong as we do with the other [teen vaccines]."

Clinician, non-teaching practice

"I'm comfortable with them waiting on the HPV vaccine; I'm not comfortable with them waiting on DTaP or meningitis."

Clinician, non-teaching practice

2. Clinicians used one of two distinct strategies to present the HPV vaccine. Neither elicited negative responses from families.

Presenting HPV in the same was as other routine vaccines

"I mention it at 11 because that's when the other booster vaccines are due so that helps me in my endeavor to try to vaccinate, by saying you're due for these vaccines."

Clinician, urban teaching practice

"I told her about the vaccines she was due for [including HPV]."

Clinician, urban teaching practice

Presenting HPV as optional and highlighting the risks and benefits of the vaccine

"He said [HPV] was something that was optional or we could talk about it later, and the others... were not optional."

Mother, age 39

"[The doctor] discussed the side effects....and reducing the chances of her getting the virus...that was helpful."

Mother, age 30

"I do explain that it is optional because...it's not like you have to get it for school or anything like that."

Clinician, urban teaching practice

"Part of [why we don't press the vaccine] is, at least currently, [because of the] school regulations... the parents will get messages about [the other vaccines] but they won't get messages about [HPV]."

Clinician, non-teaching practice

3. Teens considered themselves passive participants in decision making, even when parents and clinicians reported including them in the process.

What did you think about not getting the vaccine?

"It doesn't matter, I didn't really care about it either way."

Teen, age 13

"I think there was one [vaccine I was eligible for] but I'm not sure what it was for exactly, like what it was called."

Teen, age 13

"I don't like needles...why it got to be a needle? Instead of that shot up the nose like the flu."

Teen, age 12

Was your daughter involved in the conversation?

"[My daughter] was here, but of course she didn't want to get it...because she don't like no needles, but I said OK."

Mother, age 51

"[The decision] was mine. She don't know what [the vaccine] is."

Mother, age 44