Graduation Year


Document Type




Degree Name

Doctor of Public Health (Dr.PH.)

Degree Granting Department

Community and Family Health

Major Professor

Ellen M. Daley, Ph.D., MPH

Co-Major Professor

Dinorah Martinez Tyson, Ph.D., MPH

Committee Member

Cheryl A. Vamos, Ph.D., MPH

Committee Member

Nancy Romero-Daza, Ph.D., MA

Committee Member

Jason Beckstead, Ph.D.


cancer prevention, HPV vaccine, HPV vaccine school-entry requirement, Puerto Rico, vaccine mandates


Human Papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the US. Infection with low-risk HPV (i.e., 6 and 11) can cause genital warts, and persistent infection with high-risk HPV types (i.e., HPV 16 and 18) can progress to cancer. Currently, there is an HPV vaccine that is recommended for boys and girls, aged 11 to 12. Healthy People 2020 established a national objective of 80% completion of HPV vaccination among children aged 13 to 15 years old. Although the HPV vaccine is proven to be a safe and effective primary prevention strategy, uptake and completion rates remain low in the US.

Vaccination mandates for school entrance are an effective strategy to improve vaccination coverage. In the US, HPV vaccine policies vary; some legislate in favor of educational campaigns, while others require health insurance to cover the HPV vaccine or require it for middle-school entry. Currently, only Virginia, Rhode Island, and Washington DC require the HPV vaccine for school entrance. In Puerto Rico (PR) the Department of Health recently approved the HPV vaccine school-entry requirement for children 11 to 12 years old, starting in fall 2018.

Despite HPV vaccination’s cancer-preventive properties and vaccine mandates’ effectiveness, HPV vaccine school-entry requirements have not been widely adopted in the US. Guided by the Multiple Streams Approach, the purpose of this study was to understand the adoption process of PR’s HPV vaccine school-entry requirement. Phase 1 consisted of an HPV vaccine school-entry approval process (in favor/against). Purposive sampling was used to recruit stakeholders identified from online sources, by consulting local experts, and utilizing snowball sampling. Interviews were audio-recorded and transcribed. Data were analyzed using applied thematic analysis. Phase 2 consisted of a content analysis of PR’s newspapers from January 1st, 2015 to July 31st, 2018. Data were described quantitatively and qualitatively.

From 21 stakeholders that were interviewed, only one person expressed views against the HPV vaccine school-entry requirement. The stakeholders highlighted problems such as, the high incidence of HPV and HPV-related cancers in PR (e.g., cervical/oropharyngeal) that needed to be resolved. Social factors such as the case of Rhaiza López Plumey, a young mother, who died of cervical cancer in 2015, and the VOCES HPV Advisory Panel Report served as focusing events that motivated the adoption process. Stakeholders also discussed other policy initiatives, such as changes to the current immunization law. The political turn-over in key government positions facilitated the adoption process. During the summer of 2017, a policy window opened, and the HPV vaccine school-entry requirement was adopted in the summer of 2018. The policy entrepreneurs worked on what was needed for the HPV vaccine school-entry requirement to be adopted through collaborations among different sectors.

A total of 286 news articles included the key terms “HPV” or “human papillomavirus” in Spanish. Thirty-four articles mentioned the HPV vaccine school-entry requirement. The highest number of publications that mentioned the HPV vaccine school-entry requirement in PR occurred in 2017, and during the first seven months of 2018. The arguments listed in the articles included concerns related to the side effects of the HPV vaccine, the sexual nature of the transmission of the virus, and that it should be the parents’ right to choose to vaccinate their children. Other areas such as the HPV clears by itself and that there is no consensus regarding the HPV vaccine, were mentioned less frequently. Findings from this study can inform other states and public health practitioners interested in adopting HPV vaccine policy initiatives to improve HPV vaccination rates across the US and target the prevention of HPV-related cancers.

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