Barriers to HPV Vaccination Among Unvaccinated, Haitian American College Women

As college women, young Haitian American women are at great risk of human papillomavirus (HPV) acquisition, and they are also at a stage where they may play a major role in HPV vaccine decision-making for themselves. Furthermore, this population is at high risk of cervical cancer, but their HPV vaccination rates are low. Studies investigating factors that influence HPV vaccine uptake among groups who are disparately affected by cervical cancer are lacking, and these studies can facilitate message tailoring for ethnic minorities. The present study investigated barriers to HPV vaccination among Haitian American college women.

Recruitment for this study took place at a large minority-serving university in the southeastern part of the United States (US). Thirty participants were recruited who self-identified as Haitian, female, and between 17 and 26 years of age. A series of semi-structured, yet flexible, questions were developed based on relevant research. Interviews were conducted between June 2014 and March 2015.

Among the 30 participants, 18 (60%) had not initiated the vaccine series; 8 (26.7%) had received the first; and 4 (13.3%) had received all 3 HPV vaccine doses. Unvaccinated young women were asked their reasons for not initiating the HPV vaccine series. The results are organised around 4 major themes (and supporting quotations are provided):

1. Lack of physician recommendation: Of the 18 participants who had not initiated the vaccine series, 9 stated they had not received a provider recommendation for the vaccine. Example: "He did not ask me. The initial question is always 'Are you sexually active?' And I am like 'no.' It would stop there. They would never ask me 'Have you heard of this or would you like to get that?'" Five stated they could not recall their healthcare provider recommending the vaccine.
2. Negative vaccine perceptions: Ten of those who were unvaccinated perceived HPV vaccine as a preventive measure for sexually active individuals; 5 pointed out that they did not take the vaccine because (in their opinion) the vaccine is for sexually active women and they were not sexually active. Four participants mentioned that the vaccine was not mandatory for school attendance. Hence, they did not feel a sense of urgency to get the vaccine.
3. Negative vaccine attitudes: Seven participants expressed negative attitudes toward vaccines in general or the HPV vaccine.
4. Side effect concerns: Eight participants expressed side effect concerns regarding vaccines and medications in general. Newness of the vaccine was cited among the reasons for nonvaccination (n=3); one participant stated that her mother felt that it was necessary to wait and see how individuals who have taken the vaccine react to it. Some participants have also mentioned adverse effects that were based on television commercials prompting individuals who have taken certain medications to contact law firms for potential compensation.

The researchers observe that, although a physician recommendation does not always result in immediate vaccine uptake, it is a very important factor in medical decision-making among Haitians. Haitian mothers highly value physician recommendations when making medical decisions, and in adolescents' and young adults' health decision-making, mothers play a central role. Study results indicate that Haitian American college women themselves also value physician recommendations in their HPV vaccine decision-making. Thus, the lack of recommendation undermines the importance of the vaccine.

The researchers further suggest that, during medical visits, health practitioners should take the opportunity to not only make the recommendation to unvaccinated individuals but also to inform these patients that the vaccine has been licensed since 2006 and that its side effects are similar to those of required vaccines.

Unvaccinated participants have articulated their perception of the vaccine as a sexually transmitted infection preventive measure for sexually active women, women with multiple sex partners, and those who have unprotected sexual intercourse. Because sexual abstinence is the cultural expectation for young, unmarried Haitian women, a vaccine recommendation in the context of sexual activity is culturally inappropriate and will likely result in vaccine refusal. Thus, the researchers stress that providers should refrain from asking participants about their sexual activity when recommending the vaccine and instead communicate that HPV vaccine is directed at the prevention of HPV-related cancers and that it is meant for all eligible patients.

The researchers indicate that studies examining HPV vaccine uptake among adolescent boys and young men from ethnic groups disproportionately affected by HPV-related morbidity are needed.

In conclusion: "Haitian American college women highly value provider recommendations for medical decision-making. Their high esteem of provider recommendations provides an opportunity for education that will dispel HPV vaccine myths and help engender positive HPV vaccine perceptions."