HPV Vaccine Promotion: The Church as an Agent of Change

"SBCC [social and behaviour change communication] is systematic, targeted, and participatory and may effectively shape future HPV prevention messages in this...church community."

The high human papillomavirus (HPV)-associated cancer statistics among African Americans highlight the need to increase HPV vaccination coverage among this population. Religiosity is high for African American populations, and research shows that African American women often base health decisions - more specifically, vaccine decisions - on their strong religious beliefs. In states with high religiosity, like Georgia, exploring the roots of receptivity and hesitancy towards HPV vaccination among faith communities may allow for the cultivation of tailored church-based HPV prevention strategies. To that end, this qualitative case study sought to develop a better of understanding of HPV and HPV vaccination perceptions within an African Methodist Episcopal (AME) church to provide context for future HPV prevention efforts.

From April to July 2018, the researchers held seven focus group discussions (FGDs) with 49 leaders and members (including parents, young adults, and adolescents) of an AME church in metro-Atlanta, Georgia. Groups were stratified to capture a diversity of views on the study topics and to minimise power dynamics across group participants for open discourse - for example, not having a church leader and church member in the same group. Participants were recruited by a familiar, trusted member of the AME church, who distributed fliers about the study amongst the congregation and in a monthly church newsletter and described the study through interpersonal communication with eligible members.

A social and behaviour change communication (SBCC) conceptual framework was used to identify potential avenues to strengthen communication and health promotion strategies in the church community. The SBCC framework aimed to provide guidance to stimulate preventive actions while shifting communal perceptions to foster a supportive community for long-term behaviour change.

Results, in brief:

Barriers to the HPV vaccine: Participants discussed a multitude of barriers to vaccine uptake across all FGDs, including:

• Mistrust in the healthcare system, which was generally attributed to past unethical medical studies, like the Tuskegee Syphilis Study, conducted on African Americans without their full knowledge and consent. Participants debated if HPV prevention strategies through the medium of televised commercials (i.e., that employ scare and guilt tactics) are effective or ineffective at alleviating preconceived mistrust in the healthcare system. A participant shared, "Because it's in the media it doesn't do anything for my suspicions...because I have the same suspicions about the media! That hasn't made it a more personal way in order to get me this information or to talk to me about it".
• The expectation of abstinence among adolescents until marriage, which stems from participants' religious teachings. It was expressed that this communal expectation has prevented discussion of adolescent sexual health topics in the church setting, including HPV or the HPV vaccine. Notably, the HPV vaccine is recommended for 11- to 12-year-olds, regardless of sexual activity.

HPV vaccination perceptions: A wide range of perceptions on the HPV vaccine were identified; they fall along a spectrum. At one end of the spectrum, participants viewed the HPV vaccine as completely unnecessary. Some believed the HPV vaccine acts as a signal to their adolescent child that it is okay to have sex or felt they would face communal stigmatisation due to the perceived interference with abstinence until marriage. Many participants said they are unsure because they do not have "enough knowledge to make a decision", emphasising the need for additional HPV information and education. Still others expressed perceived motivators for vaccination that outweighed the perceived barriers.

Opportunities for future HPV prevention strategies: Participants across FGDs shared a desire to break down the taboo of discussing sexual health in the church and the communal mistrust held towards the healthcare system. The value of transparency from trusted sources - especially from populations who share characteristics of their social network (e.g., race/ethnicity, religion) - was an emergent theme among participants' recommendations for future HPV prevention efforts. Church leaders were receptive to moving forward from suspicions and stigma surrounding the HPV vaccine to advocate for preventive health within the church community. Participants highlighted the positive influence of pre-established trust in church-based interventions, with one participant explaining, "it plays a part in how receptive you are to the education if it's coming from someone that you're familiar with".

Thus, because church leaders hold the trust of their congregation, "implementation of a church-based intervention utilizing the SBCC strategies has considerable potential to transform perceptions of the HPV vaccine and increase vaccination uptake." Specifically, for HPV vaccine promotion in this AME church community, the five SBCC strategies identified are:

1. Faith-based mobilisation - e.g., to make HPV vaccination a priority, it is important to inform church leaders of the low vaccine coverage rates in Georgia and how HPV-related cancers disproportionately affect African Americans.
2. Community mobilisation - e.g., this would entail the health ministry (of the AME) changing the social, cultural, and institutional norm of it being taboo to discuss sexual health in the church to establishing an environment where adolescent sexual health topics are openly discussed, including sensitisation on HPV prevention and vaccination.
3. Community engagement - e.g., preestablished trusted community leaders, such as AME's health ministry, could create tailored health communication messages - sharing them at health fairs or health forums - that are socially and culturally appropriate.
4. Social change communication - e.g., AME's health ministry could provide consistent evidence that HPV vaccine uptake is not associated with earlier sexual debut or increased promiscuity and that, instead, it is designed to prevent cancer-causing infections long before they may be exposed to the virus.
5. Behaviour change communication - e.g., successful implementation and receptivity of the previous four SBCC strategies in the AME church may result in behaviour change (i.e., uptake of the HPV vaccination series for adolescents).

In conclusion: "These findings may be implemented in future HPV vaccine promotion strategies within faith-based communities to promote safe and open dialogue for health communication messages to be disseminated in a familiar and trusted setting."