Assessing the Interrelationship between Stigma, Social Influence, and Cervical Cancer Prevention in an Urban Underserved Setting: An Exploratory Study

"[T]here are direct and indirect differences in the way that women and men express their perceptions around HPV infection or a cervical cancer diagnosis, especially related to perceived public stigma, blame, personal responsibility, empathy, valuing prevention, and valuing reliable information."

Despite affordable access to primary and secondary prevention cervical cancer measures at Federally Qualified Health Centers (FQHCs) in the United States (US), human papillomavirus (HPV) vaccination and screening rates among racial/ethnic minorities and low-income women are low, suggesting the role of non-financial barriers. For example, stigma around sexual behaviour and HPV infection may contribute to vaccine and screening hesitancy by causing individuals to avoid engagement with providers. The objectives of this exploratory study were to explore the role social influences in general, and stigma in particular, play in influencing the acceptability of cervical cancer prevention services among parents and legal guardians of vaccine-eligible girls attending an urban FQHC clinic.

Study participants included eight mothers, one father, and two grandparents/legal guardians in Chicago, Illinois, US. Nine participants self-identified as Black/Afro-Caribbean, or African American, two as Latinx, and one as Native American. The quantitative data suggested discordance between participants' cervical cancer prevention knowledge and their practices. Most indicated that their daughters had received the HPV vaccine but were unsure about HPV transmission modes. Qualitative data revealed that participants were comfortable disclosing information on HPV infection and vaccination status, and most women were likely to share information related to cervical cancer testing and diagnosis. In fact, participants reported that the sharing of personal stories regarding cervical cancer prevention is a good way to influence others to make similar choices. One participant stated, "Because I feel confident about the decision. Now it might help another family, another parent. It may not, but still, I am going to share. Yeah."

While participants did not stigmatise HPV and cervical cancer themselves, there was frequent expression of perceived public stigma (shaming and blaming women) - particularly with respect to HPV infection. Women participants' expression of perceived public stigma indicates a fear of being discriminated against, as there is a view that others may hold prejudices toward women who are HPV positive or diagnosed with cervical cancer. Participants also discussed gender differences (men are indifferent to risk, they asserted) and distrust of the HPV vaccine itself, of the doctors who are recommending the vaccine, and of the healthcare system as a whole. Indicative of the latter theme was one remark from a participant who said, "A lot of doctors are not good out here. Some doctors are in it for the money. And some doctors, in my way of life....By me being African American, it's a stigma towards doctors that won't treat African Americans as well as another race. So our stigma towards doctors are not well."

The findings highlight several concepts, including the disharmony between practice and knowledge, prevalent perceived public stigma (including dismissive attitudes on the part of men regarding HPV and cervical cancer), distrust of the healthcare system, and the promise related to positive social influence (e.g., sharing information within social circles may be a good way to build knowledge and influence decisions of family members or close contacts relative to HPV and cervical cancer prevention).

The researchers suggest that future public health interventions should:

• Focus on a unified message to increase the understanding of the relationship between HPV and cervical cancer, as well as the various modalities for the prevention of cervical cancer.
• Address men's attitudes, in particular, regarding HPV and cervical cancer. Men's attitudes and women's perceived attitudes may contribute to the study's finding of perceived public stigma.
• Pursue more research to understand the relationship between observable stigma and the practice of HPV vaccination and cervical cancer screening. It is likely that decision makers are discouraged from the uptake of cervical cancer prevention services due to these social factors.
• Leverage positive social influence to address distrust of the healthcare system, which adversely affects uptake.