In the US, routine administration of quadrivalent HPV vaccine is recommended for girls and boys at 11-12 yrs, with catch-up vaccination recommended up to 26 yrs for girls, and 21 yrs for boys.  The difficulty has been in the implementation of the recommendation: overall rates of initiating and completion among US teenage girls currently stand at 57% and 35% respectively, according to data from NIS-Teen (CDC/MMWR 25.7.14).  This is of particular of concern, since there is evidence both from the US and from the UK that those most at risk (e.g. ethnic minorities) happen also to be those who are most likely to miss out on vaccination (STI/Niccola & Hadler; STI/Sacks & Robinson; STI/Liddon & Hadler). What is the reason for this poor uptake?  NIS-Teen, on the basis of recent survey evidence, claim that the lack of strong provider recommendation may often lead to missed vaccination opportunities (STI/blogs/”catch-up”).  (Kepka & Seraya (STIs) discuss the difficulty of ensuring the conformity of providers with HPV guidelines).  Yet, how, in practice, do these missed vaccination opportunities occur between well intentioned parents and providers who wish to protect adolescents from developing cancer as adults?

A recent qualitative study (Perkins & Pierre-Joseph), based on interviews with 124 parents/guardians and 37 providers in one large public clinic and three smaller private ones, offers an illuminating insight into the conversational moves characterizing the kind of real-life discussions between provider and parent that lead to missed opportunities – most often through the decision to delay the initiation of HPV vaccination.  The report analyzes these in considerable detail.  Typically, however, it is a question of a “complicity” between the conversational partners in respect to broaching the topic of the daughter’s sexual behaviour, taking the form of a tacit agreement to postpone the discussion about vaccination until a more appropriate time.  The script generally runs: “My doctor asked me if I thought if she was sexually active and I said no and then she said that there was plenty of time”.

The authors’ recommendations, based on the strategy of providers achieving rates of ≥ 80%, are: co-adminstration with tetanus and meningococcal vaccine, focussing on cancer prevention benefits and vaccine safety, and expressing a strong recommendation (i.e. “expecting a yes”) – in short, routinizing and normalizing HPV vaccination.

Not the least interesting aspect of their findings was the very considerably greater success of the ethnically diverse public clinic as against the majority white private clinics in initiating vaccination (77% vv. 54%, according to the electronic medical record).  More can be less, it would seem, when it comes to certain public health interventions.