Facilitators and Barriers to the Implementation of the HPV VACs (Vaccinate Adolescents Against Cancers) Program

A Consolidated Framework for Implementation Research Analysis

Cam Escoffery, PhD, MPH; Kara Riehman, PhD; Lesley Watson, PhD; A. Sandy Priess, MIS; Marcie Fisher Borne, PhD; Sean Nathaniel Halpin, MA; Carlie Rhiness, MPH; Emily Wiggins, MPH; Michelle C. Kegler, DrPH


Prev Chronic Dis. 2019;16(7):e85 

In This Article

Abstract and Introduction


Purpose and Objectives: The human papillomavirus (HPV) vaccine is an effective but underused method for preventing multiple cancers, particularly cervical cancer. Although interventions have successfully targeted barriers to HPV vaccine uptake in various clinical settings, few studies have explored their implementation. Our study examines the delivery of the HPV VACs (Vaccinate Adolescents Against Cancer) Program and elicits information on barriers and facilitators to implementation.

Intervention Approach: The VACs Program pilot was a multilevel, evidence-based intervention conducted by the American Cancer Society in 30 federally qualified health centers (FQHCs) in the United States.

Evaluation Methods: We conducted in-depth interviews (N = 32) by telephone with representatives of 9 FQHC partners. We structured the interview guides on Consolidated Framework for Implementation Research (CFIR) domains. We asked about project start-up activities, implementation strategy selection, policy- and practice-level changes, staffing structure, challenges, and key factors leading to project success. At least 2 researchers coded each interview transcript verbatim.

Results: Participants most frequently identified the electronic health record system, training and education, concrete tools and resources, and provider champions as facilitators to implementing HPV VACs. Limited staff resources, challenges of electronic health records, issues with state immunization registries, patient misinformation about vaccines and vaccine stigma, cultural/language barriers, competing priorities, levels of funding, staff buy-in, training needs, and low health literacy were identified as barriers.

Implications for Public Health: Providing appropriate training for FQHC staff members and providers along with technical assistance and facilitation tools were critical for increasing provider confidence in recommending HPV vaccine. Addressing capacity-building and implementation barriers in FQHCs can increase effective implementation of evidence-based interventions to increase HPV vaccination uptake and reduce the burden of future cancers.


About 4 of 5 people in the United States will get human papillomavirus (HPV) at some point in their lives.[1] Each year, an estimated 32,500 Americans receive a diagnosis of cancer associated with HPV.[2] Through HPV vaccination, about 29,000 cases of cancer could be prevented each year in the United States.[2] Despite this opportunity, only 60% of adolescents in the United States initiated HPV vaccination in 2016, and only 43.4% of those aged 13 to 17 were up to date with the HPV series (49.5% for girls; 37.5% for boys), leaving many children exposed to future cancer risk.[3,4] The Centers for Disease Control and Prevention estimates that if the HPV vaccine were routinely given with other recommended vaccines, HPV vaccination rates could exceed 90%.[5]

Many barriers to HPV vaccination exist, including providers' ability to give a confident recommendation to vaccinate, parental hesitancy, and missed opportunities to vaccinate.[6] A provider recommendation is one of the strongest predictors of HPV vaccination; parents who receive a strong recommendation are more likely to vaccinate their adolescent than those who do not.[7–9] HPV vaccination is also influenced by practice factors, such as adequate health information systems that include provider or patient prompts for vaccine administration.[10] Interventions to address both provider capacity to deliver an effective recommendation to parents and system challenges have increased HPV vaccination rates in various clinical settings.[11] However, few explorations of the delivery of HPV vaccine interventions have been studied qualitatively. The Consolidated Framework for Implementation Research (CFIR) is a theoretical model often used in implementation research to study factors that affect implementation through quantitative or qualitative methods.[12] Only 2 qualitative studies have explored barriers (eg, lack of appointment reminders, language) and facilitators (eg, publicity about the vaccine) related to HPV vaccination in health centers across the CFIR domains.[13,14] More research is needed to explore the prevalence of these barriers and facilitators across health care settings and populations served.