Objectives: Australia was one of the first countries to implement a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies describing or explaining decision-making processes and behaviour post-implementation of HPV vaccination of adolescents. We aimed to investigate the experiences, beliefs, and decision-making of adolescents, parents, teachers, and vaccination nurses involved in a school-based HPV vaccination program.

Methods: A purposive sample of 9 schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and school types (Catholic, Independent or Government). Semi-structured focus groups and interviews with participants (n= 185) were conducted until saturation was reached. Transcripts were analysed inductively and emergent themes were subject to constant comparison.

Results: An explanatory model of decision-making and behaviour (figure 1) was constructed from the data. Five decision making groups emerged across a continuum of vaccination behaviour: active decision-making--vaccinated, passive decision-making--vaccinated, passive decision-making--not vaccinated, active decision-making--not vaccinated, and active decision-making--anti-vaccination. A range of factors influenced participants in each of the decision-making--behaviour groups. Adolescents were often part of the decision-making process; mostly this resulted in decision agreement. Where adolescents were not involved, non-agreement sometimes occurred.

Conclusions: Our research suggests that there are several processes of decision-making and behaviour in adolescent HPV vaccination. We have presented a variety of paths that girls and their parents experience to arrive at a decision and behavioural outcome about HPV vaccination. Attitudes, past experiences and worldviews contributed to this process.