Decision-Making Process of Families about Human Papillomavirus Vaccination of Adolescent Daughters: A Qualitative Study of Hong Kong Chinese Families

Human papillomavirus (HPV) vaccination became available in the private sector in 2006 in Hong Kong. Promotion of HPV vaccination occurs mainly through advertising from the pharmaceutical industry. By 2012, only about 7% to 9% of teenage girls had received HPV vaccination. This study aimed to identify the underlying barriers and facilitators about HPV vaccination of adolescent daughters in Chinese families.

For the study, 51 respondents (35 mothers, 15 adolescent girls, and one father) from 35 families were interviewed between March and September 2013. Of the 35 families, 5 (14%) had daughters who had been vaccinated against HPV.

The researchers learned that most parents whose daughters had not been vaccinated against HPV had had no formal discussions about vaccination, as there was no perceived and immediate need. Many mothers and daughters had never discussed HPV vaccination with fathers, perceiving that men were uninterested and ignorant about a "female topic". Mothers often reported that fathers felt embarrassed when these issues were considered, so the decisions tended to fall to mothers and daughters. However, when fathers held strong negative opinions, mothers' opinions were influenced. Most parents who currently declined HPV vaccination stated they would reconsider when their daughters grew up, by which time they felt that the vaccine will have been evaluated more thoroughly.

The factors influencing HPV vaccination decision making were found to be:

• General attitude towards and experience with vaccination - All parents ensured that their children had received government-mandated vaccines, but some expressed reluctance towards optional vaccines, either owing to negative experiences (such as unpleasant adverse effects) or a preference for "natural immunity".
• Knowledge and perceptions about HPV and cervical cancer - Both parents and daughters reported not knowing much about cervical cancer or HPV. Almost all parents and some senior girls linked sexual activity with cervical cancer, and some mothers and girls attributed cervical cancer to promiscuity. Some mothers believed that heredity, unhealthy diet, stress, and environmental pollution also contributed to cervical cancer.
• Reasons for accepting HPV vaccination - For many parents and girls who accepted HPV vaccination, fear/worry about cervical cancer was a key motivating factor, although some girls did not know exactly what cervical cancer was. Despite few participants ever having received a recommendation for HPV vaccination from healthcare professionals, concrete advice, particularly from trusted doctors, was a key cue to action for those who received it. Some participants were confident about the safety and efficacy of HPV vaccination, as they (incorrectly) perceived that the vaccine was promoted by the government. Some participants reported that their friends had been vaccinated or had vaccinated daughters without experiencing any apparent side effects, and this reduced their concerns.
• Reasons for declining/delaying HPV vaccination - Many parents perceived that the susceptibility to HPV infection was lower than that to other childhood diseases owing to the difference in transmission modes. This was particularly so in participants who attributed cervical cancer to promiscuity. Religious faith was cited by some parents who declined the HPV vaccine. Others expressed concerns about vaccination safety or questioned the effectiveness of the vaccination and duration of protection. Many parents saw no immediate need because their daughter was not likely to become sexually active anytime in the near future. Among mothers who declined the HPV vaccine, despite the lack of communication or discussion within family or with peers, any disapproval from other significant family members or friends significantly hampered their decision making. Several mothers reported that despite initiating consultations with family doctors, they failed to receive concrete advice. Some parents saw it as uneconomical or discretionary consumption and declined it.

Key messages:

• Social influences significantly affect the decision-making process of parents and adolescent girls about HPV vaccination.
• Governmental involvement and recommendations from trusted healthcare professionals are important facilitators of decisions about HPV vaccination.
• Doubts about the necessity, safety, efficacy, and high cost of vaccination are barriers to HPV vaccination. Vaccination costs contribute to inequalities in women's health, especially among lower socioeconomic groups.
• The government should subsidise a school-based HPV vaccination programme against HPV for all Hong Kong girls.
• Future HPV vaccination programmes should focus on the necessity of early vaccination and provide unbiased information about safety and efficacy.
• A programme to educate primary care doctors should be initiated to improve parents' knowledge about HPV vaccination. However, this is unlikely to be an effective strategy for new immigrant and low-income families who remain suspicious about the fiscal motives of private clinicians.