Year of Award


Document Type


Degree Type

Doctor of Philosophy (PhD)

Degree Name

Public Health

Department or School/College

School of Public and Community Health Sciences

Committee Chair

Sophia R. Newcomer

Commitee Members

James Caringi, Erin Landguth, Tony Ward, Allison Young


cross sectional study, ecologic analysis, HPV vaccination, immunization nurses, rural public health departments, semi-structured interviews


University of Montana


Purpose: Parental vaccine hesitancy is a known driver of sub-optimal vaccine uptake in the United States.1 Even though a study analyzing parental responses in National Immunization Survey-Teen found that HPV vaccine hesitancy has slightly declined (69% in 2010 v/s 63% in 2019) over the years, only about 52.6% of adolescents in Montana had received all the required doses of the HPV vaccine series in 2021.2,3 Nurses are at the forefront of healthcare provision and possess a unique ability to influence parental vaccine decisions.5 By listening to and addressing parents' concerns about immunizations, nurses can dispel misinformation and help change parents' perceptions about the risks associated with immunizations.6 However, lack of research focused on ascertaining vaccine confidence among nurses impedes the development of evidence-based strategies to effectively engage nursing professionals in HPV vaccine promotion in Montana.

Methods: Aim One: I conducted a statewide cross-sectional survey of Montana nurses and medical assistants (n=309) working at facilities participating in the Vaccines for Children program to determine their perceptions, practices, and experiences with adolescent immunization services, with a focus on HPV vaccination. Aim Two: I conducted qualitative interviews with public health nurses (n=21) employed at public health departments with both higher and lower missed opportunities rates for HPV vaccination to isolate patient-, provider-, and clinic-level factors associated with higher or lower HPV vaccine uptake. For Aims 2 and 3, I defined a clinic visit to be a missed opportunity for HPV vaccination, when an adolescent received other recommended vaccines (Tdap, MenACWY, Influenza) but did not receive an HPV vaccine dose during the visit despite being due or overdue to initiate the vaccine series. Aim Three: Using immunization data from Montana's immunization information system, I conducted an ecologic analysis = and used generalized linear mixed modeling to identify county-level sociodemographic and access-to-care factors that were associated with missed opportunities for HPV vaccination across all clinic settings.

Results: Aim One: In the statewide survey, most respondents (92.5%) agreed that it is important to vaccinate adolescents against HPV before they engage in any physical intimacy. About 38.1% of respondents reported that misinformation that parents receive from the internet and social media were major barriers to HPV vaccine uptake. Regarding strategies to improve vaccination rates in Montana, 61.4% nurses and medical assistants identified emphasizing cancer prevention while discussing HPV vaccine as being very effective. Aim Two: Qualitative interviews with public health nurses revealed that among all recommended adolescent immunization, nurses faced most parental vaccine hesitancy with the HPV vaccine. A lack of robust reminder/recall systems, quality improvement initiatives, and vaccine recommendation styles influences community HPV vaccination rates. Public health nurses underscored the need to engage adolescents through tailored vaccine messaging, create training opportunities for nurses in effective vaccine conversations, invest in social media campaigns, encourage collaborations with schools and community organizations, and promote HPV vaccination at every patient encounter. Aim Three: County level effects of population density, rurality, income inequality ratio, proportions of families receiving public assistance, proportion of American Indians/Alaska Natives, and children in single-parent households were significantly associated with missed opportunities for HPV vaccination after adjusting for individuals' age group and gender (p-value 0.05). Increases in county-level estimates of rurality were associated with higher odds of experiencing HPV missed opportunities whereas increases in proportions of families receiving public assistance, proportion of American Indians/Alaska Natives, income inequality ratio, children in single parent households, and population density were associated with lower odds of experiencing missed opportunities for HPV vaccination.

Conclusion: Nurses, along with other health professionals, play a key role in increasing vaccination rates and their contribution toward primary prevention of HPV-related infection is crucial. However, multi-level strategies are required to support the integration of nurses as active HPV vaccine advocates and increase HPV vaccine use in rural and medically underserved areas. The ecologic analysis presented an efficacious way of identifying geographical disparities in HPV vaccine uptake risk, thus helping focus resources on populations in need.



© Copyright 2023 Juthika Jayendra Thaker