African-American Parents' and Daughters' Beliefs about HPV Infection and the HPV Vaccine

"...findings have implications for the development of culturally and developmentally appropriate interventions to promote HPV vaccination among African-American parents and their daughters."

Contention still surrounds acceptance of the human papillomavirus (HPV) vaccine among parents, religious conservatives, and public health officials in the United States (US). Among African Americans, HPV vaccine acceptance has found to be influenced by religious beliefs and by concerns that HPV vaccination may suggest to children that parents condone premarital sex. Beliefs that vaccination is medical experimentation and mistrust of the medical profession are other factors that influence HPV vaccine acceptance among African-American parents. This study sought to increase understanding about the health beliefs of African-American parents and their daughters toward HPV infection and HPV vaccine acceptance. The Health Belief Model (HBM) was used as a guiding framework.

Principles of grounded theory, theoretical sampling, and constant comparison analysis were used to qualitatively analyse data generated from personal interviews of African-American parents (n = 30) and their 12- to 17-year-old daughters (n = 34). The interview guide consisted of open-ended questions informed by the constructs of the HBM. Interviews were conducted between June 2014 and October 2015.

Selected findings:

• Perceived susceptibility: Few parents perceived daughters to be at risk for HPV infection; they believed that their daughters were not sexually active. No daughters perceived themselves at risk for HPV infection.
• Perceived severity: Findings underscore the potential negative consequences of acquiring HPV that may extend health-related consequences for some African-American parents and daughters to include social consequences such as violating cultural norms and expectations around sexuality, potential financial burden from cancer if unvaccinated, and potential effects on their emotional and psychological well-being.
• Perceived benefits: Compared to daughters, parents placed particular emphasis on the vaccine's protection against genital warts.
• Perceived barriers: A major HPV vaccine acceptance barrier among both parents and daughters was the politicisation of the HPV vaccine by government figures. In addition, concerns about unknown side effects, safety, and effectiveness of HPV vaccination emerged. Mistrust continues, and concerns about safety linger among both parents and daughters. Among daughters, parents were a barrier to HPV vaccination: Some daughters who desired the HPV vaccine had parents who were not supportive.
• Cues to action: Parents frequently reported cues to action as a healthcare provider (HCP) recommendation, obtaining sufficient information on HPV and the HPV vaccine, and desiring to protect daughters against HPV/sexually transmitted infections (STIs) and cervical cancer. Among daughters, the most frequently reported cues to action were parental decision to accept the HPV vaccine, the desire to prevent HPV/STI infection and cervical cancer, and the wish to obtain protection in anticipation of sexual activity.
• Self-efficacy: Many parents believed in their ability to get their daughters vaccinated. However, many daughters described having little to no say in the HPV vaccination decision.

Implications for promotion of HPV vaccination among African Americans:

• It is important to increase awareness among parents about the imprecise nature of estimating initiation of sexual activity in children. Employing certain parenting practices, such as closely monitoring a child's activities and whereabouts, to estimate a child's initiation of sexual activity may be inaccurate and affect perceived risk of acquiring HPV in a problematic way.
• School-based health centres may be the appropriate setting to disseminate information about the risks of acquiring HPV and the benefits of vaccination among African-American parents and children.
• Potential actions to counteract mistrust may be to disseminate information about the HPV vaccine in other settings trusted by the African-American community such as churches.
• HCPs such as nurses may be particularly suitable to disseminate information in a culturally sensitive way, as they may provide more opportunities for families to discuss the vaccination decision by sharing literature, discussing sexual health, troubleshooting barriers, and preparing them for the vaccine administration appointment. Nurses may also target sexuality-related concerns by highlighting the necessity of vaccination prior to sexual debut for optimum immunogenicity.
• "Engaging parents in the decision before vaccination occurs may provide an opportunity for parents to align their beliefs with clinical evidence and to think about important questions they would like answered by providers involved in the vaccine administration process."

Implications for future research:

• As HPV vaccination is stigmatised due to its link to sexual activity, the findings suggest "the need for studies to address the role of cultural normative beliefs on African-Americans' decisions to adopt sexual health preventative behaviours, such as HPV vaccination....Understanding the role of contextual factors will assist in the development of culturally appropriate interventions that can take place in culturally appropriate settings."
• In light of the finding that a motivation for daughters to obtain the HPV vaccine is to be protected before the onset of sexual relations, future research "could explore the differential effects of temporally framing messages on HPV infection and cervical cancer as distal versus proximal health outcomes of sexual activity among adolescents and preadolescents."
• Daughters conveyed low self-efficacy to obtain the HPV vaccine and reported mothers as the ultimate decision makers. Interventions designed to increase self-efficacy among emergent adults and to change the attitudes of mothers, specifically older mothers who may have more negative attitudes about the HPV vaccine, could improve uptake.
• "Researching precursors of negative attitudes and mistrust may be another fruitful research avenue to pursue to inform the design of HPV vaccine promotion interventions targeting African-Americans in particular."

In conclusion, understanding the health beliefs that promote HPV vaccine acceptance, while identifying and addressing beliefs that are barriers among parents and daughters, could assist in the development of appropriate HPV vaccine promotion initiatives for African-American parents and daughters.