Using an ecological model of HPV vaccine uptake as the conceptual framework for this dissertation, influences on HPV vaccine uptake at different levels are examined, from national and state public policies to influences at the health care organization level. Subsequently, a strategy for utilizing those influences to increase HPV vaccine uptake at an organization level is tested.

First, a history of HPV vaccine policy is reviewed demonstrating that federal and state public policies were restricted in asserting responsibility for vaccinating the population, leaving health care organizations to fill the vacuum. The federal government limited its HPV vaccine policy involvement to approving the HPV vaccines through the FDA, recommending evidence-based universal vaccination for all females through the ACIP, and providing some vaccine funding to states for specific subgroups of the population through the Vaccines for Children program. State policy requirements focused on vaccine inclusion in school entry requirements, historically one of the most effective means of increasing vaccination rates at the population level, but only Virginia and Washington, DC have passed this legislation, as states argued in favor of parental rights over public health.

Second, the literature review evaluates which factors, modifiable at the patient encounter in health care organizations, influence HPV vaccine uptake. The findings include the stronger influences of cost and insurance coverage and provider recommendation, as well as other influences including vaccination opportunity, HPV and HPV vaccine knowledge, vaccine safety concerns and HPV risk.

Third, three possible strategies, aimed at eliminating cost to increase HPV vaccine uptake at the organization level, are tested. The strategies include vaccinating everyone, vaccinating no one, or targeting HPV vaccination to those at highest risk. Using decision tree analysis, very little difference in cost was calculated among the three strategies, although the least expensive strategy was to vaccinate no one, and the strategy with the best clinical outcomes was for the organization to vaccinate everyone.

Finally, a synthesis of the dissertation findings is provided, applying the research to practice, discussing the strengths and weaknesses of the research, and exploring directions for future research.