Abstract
CONTEXT: Human papillomavirus (HPV) is the most common sexually transmitted infection in the US. Despite the availability of safe and effective vaccination to prevent these infections, vaccination rates have remained suboptimal. To design effective evidence-based strategies, a robust understanding of the facilitators of HPV vaccination is needed. Despite the important role of public health departments in rural immunization services delivery, HPV vaccination practices in such settings have not been well described. OBJECTIVE: This study aimed to examine multilevel factors that influence HPV vaccination practices within rural public health departments, and to identify strategies used by public health departments in promoting vaccination for adolescent patients. DESIGN: We conducted in-depth, semistructured exploratory interviews with 21 immunization nurses between June and August 2022. We used a positive deviance design to sample nurses working in county public health departments that were in the top and bottom quartiles for the proportion of missed opportunities to vaccinate against HPV. Transcripts were reviewed independently by 2 interviewers and analyzed to identify key themes. PARTICIPANTS: Immunization nurses working in rural public health departments in Montana. RESULTS: Interviews with 21 nurses revealed that increased parental hesitancy toward the HPV vaccine and the communication styles used during vaccine discussions were key factors influencing HPV vaccine uptake among adolescents receiving care at rural public health departments. Participants highlighted the need to engage adolescents through tailored vaccine messaging, create training opportunities for nurses in vaccine conversations, invest in social media campaigns, encourage collaborations with schools and community organizations, and promote HPV vaccination at every patient encounter to improve vaccination rates. CONCLUSION: Public health nurses play a crucial role in adolescent immunization services delivery in rural areas. Identifying vaccination strategies implemented by higher-performing public health departments is critical for informing future initiatives.