HPV Vaccine Acceptance among African-American Mothers and Their Daughters: An Inquiry Grounded in Culture

"The majority of prior research has been informed by traditional health behavior change theories, which leads to a focus on personally derived attitudes at the expense of contextual influences such a culture."

A growing body of literature suggest that cultural factors, such as mistrust of healthcare providers (HCPs) and the healthcare system, religion, and social norms related to appropriate sexual behaviours, play a prominent role in human papillomavirus (HPV) vaccine acceptance among African-Americans. However, in the estimation of this group of researchers, prior studies have not been directly informed by theoretical approaches that more broadly describe the factors that are shaped by culture. Thus, in this study, they explore the influence of culture on African-American mothers' and daughters' HPV vaccine acceptance using the PEN-3, a culturally-centred conceptual framework developed by Collins Airhihenbuwa.

The 2 domains of the PEN-3 used to operationalise culture in this study are:

• The Relationships and Expectations domain, which identifies perceptions (knowledge, attitudes, beliefs), enablers (community, environmental, structural factors), and nurturers (family, support networks) as factors that influence the person, family, and/or community's actions towards performing a health behaviour.
• The Cultural Empowerment domain, which provides criteria for categorising perceptions, enablers, and nurturers as positive (promotes the behaviour), exotic (is unfamiliar to western medicine, not harmful, and not necessarily influencing health behaviour), or negative (is a barrier to performing the health behaviour).

Grounded theory techniques were used to explore cultural factors that influenced the acceptance of the HPV vaccine among African-American mothers (n=28) and their daughters (n=34) between the ages of 12 and 17 years. Participants were interviewed once between June 2014 and October 2015. The interview guide was developed based on the constructs of the PEN-3 and included questions about factors that influenced HPV vaccine acceptance.

A majority of daughters had not initiated the HPV vaccine series (n=22, 64.7%); however, among those who had, the majority had completed the 3-dose series. Regardless of daughters' HPV vaccination status, a majority of mothers and daughters held positive attitudes and beliefs towards vaccines in general. Mothers' attitudes and beliefs towards vaccines in general were influenced by their positive experiences with vaccines during childhood, in which vaccinations prevented mortality occurring as a result of infectious diseases. Daughters' positive attitudes and beliefs towards vaccines in general were based on their belief that vaccinations were beneficial, while also acknowledging that vaccinations may have side effects.

Among parents who initiated the HPV vaccination series for their daughters, all of them reported that their positive attitudes and beliefs towards the HPV vaccine were enough to motivate their HPV vaccine acceptance. This finding was similar for daughters. Among mothers who did not initiate the HPV vaccine series for their daughters, negative attitudes and beliefs stemmed from concerns about side effects and perceptions such as that the HPV vaccine was too new, not safe, not effective, not a vaccine for kids, or given at too young an age.

A majority of mothers and daughters, regardless of HPV vaccination status, were aware of HPV and the HPV vaccine. Mothers and daughters learned about HPV and the HPV vaccine from daughters' HCP, daughters' school, television, the internet, or from family and friends. Hearing negative messages in the media was not an influencing factor among mothers whose daughters initiated the HPV vaccine series. However, among mothers whose daughters did not initiate HPV vaccine series, a majority reported that the messages in the media were a negative influence - e.g., by making them aware of side effects. Among daughters, although they reported seeing televised HPV vaccine commercials, the commercials had no effect on their HPV vaccine acceptance, since the images on the screen did not reflect the seriousness of HPV or seem relatable to them. One HPV-vaccinated daughter said, "I always saw the Gardasil commercials but I guess I never really listened to them because they were always jumping rope or something. That's probably bad but yes I always heard the cancer part but I never really listened to if they said anything about HPV and if they said HPV I didn't really know what it was anyway."

Other findings:

• The majority of mothers and daughters did not believe that their knowledge of HPV and the HPV vaccine was adequate. Mothers and daughters lacked knowledge on the symptoms and risk factors of HPV, and on the effectiveness, safety, and side effects of the HPV vaccine. When HPV vaccine knowledge was low, mothers were reluctant to accept the vaccine.
• HCP recommendations were valued; however, mothers were often dissatisfied with the detail of information communicated.
• Spirituality and religion are core aspects of African-American culture and experience. However, the majority of mothers and daughters indicated that their religious doctrine did not impede their HPV vaccination decisions. For a few mothers, though, religious beliefs (e.g., about premarital sex) could not be separated from their HPV vaccination decisions and ultimately deterred HPV vaccine acceptance.
• Support networks provided both positive and negative types of social support to mothers and daughters. (Examples are provided.)
• Mothers reported growing up in households where conversations about sex and health were considered taboo and inappropriate for children, which made it difficult for them to have such discussions with their daughters.

According to the researchers, an important contribution of this study is the finding that negative attitudes towards vaccination may stem from the belief that vaccines are not "one-size-fits-all interventions". Specifically, a mother correctly pointed out the need to include ethnic minority populations in clinical trials testing vaccine effectiveness. Perhaps attempts to increase HPV vaccine acceptance among African-Americans could address the concern of safety and effectiveness through the increased representation of members of this population in HPV vaccine clinical trials.

The findings also indicate that when mothers' informational needs were not addressed, they were less accepting of the HPV vaccine. In fact, one mother shared her experience of declining vaccination after learning of the probability of a negative side effect from her HCP. Even though the HCP attempted to explain that the probability of a side effect from vaccination is low, it appears that the HCP missed the opportunity to compare the probability of a negative side effect with the probability of daughter contracting HPV and being diagnosed with cervical cancer. This finding suggests the need for interventions to promote HCP-patient shared decision-making and communication about HPV, the contents of the vaccine, and potential side effects.

Finally, the study illustrates that information about HPV vaccination is obtained by different sources, including social networks and the media. When family and friends verbalised fears about safety and unknown side effects, mothers and daughters were less accepting of the HPV vaccine, and mothers were more reluctant to discuss the vaccine. These findings suggest that an intervention inclusive of mothers, daughters, and the broader African-American community may be useful to promote communication to address knowledge deficits and negative perceptions around HPV and the HPV vaccine. Regarding the influence of the media, consistent messaging in HPV vaccine media campaigns from trusted information sources could possibly reduce misinformation and concerns about HPV vaccination.

In conclusion, the researchers suggest that the study findings can inform the development of culturally appropriate interventions that advances the evidence on cervical cancer prevention among African-Americans.

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