Using Social Marketing Theory as a Framework for Understanding and Increasing HPV Vaccine Series Completion Among Hispanic Adolescents: A Qualitative Study

In the United States (US), the human papillomavirus (HPV) vaccine is recommended by the Advisory Committee on Immunization Practices for females and males who are between 9 and 26 years old. However, vaccine completion rates among Hispanic females and males between the ages of 13 and 17 in 2014 were an estimated 39.3% and 21.1%, far below the the Healthy People 2020 coverage goal of 80%. The purpose of the current study is to apply the key elements of social marketing theory (i.e., the 4 Ps: product, price, place, and promotion) to assess the needs and preferences of Hispanic mothers in order to guide the development of interventions to increase HPV vaccine completion.

From May 2014 through January 2015, the researchers conducted 51 in-depth interviews with Spanish-speaking Hispanic mothers of adolescent girls and boys aged 11 to 17 in Houston, Texas, US. Participants were classified according to 2 market segments, based on their HPV vaccination status: Initiated: daughter or son had received at least one dose of the HPV vaccine, and Completed: daughter or son had completed the 3-dose HPV vaccine series. The sample consisted of 16 mothers of Initiated girls; 12 mothers of Initiated boys; 16 mothers of Completed girls; and 7 mothers of Completed boys.

Based on a literature review, the researchers created interview guides for mothers for each different market segment. The guides consisted of open-ended questions designed to elicit responses related to product (the benefits of a given behaviour), price (the potential costs associated with the behaviour), placement (the location where the behaviour will occur and individuals or entities that provide information or other goods that facilitate the behaviour), and promotion (the important features or components of designing and delivering messages about the behaviour).

Results are discussed in terms of:

• Product: The findings provide guidance regarding the types of benefits, health related and non-health related, that should be emphasised by interventions. For example, factors common to both market segments that influence the decision to have their child complete HPV vaccine series include the desire to protect their child from illness or prevent illness. Speaking with the doctor about vaccination was another, which reinforces the importance of doctors in the health decisions that parents make for their children. It was found that vaccine reminders would help mothers decide to have their child complete the vaccine series. Also, according to the Initiated mothers, completing the vaccine provides an opportunity to educate their child about maintaining good health practices.
• Price: Not having health insurance, the cost of the vaccine, and transportation were perceived barriers (costs) to vaccine series completion. Compared to general perceived barriers, informational barriers to vaccine series completion were more prevalent. For example, according to Initiated mothers, uncertainty about the number of HPV vaccine doses their child has received is a potential barrier to series completion. Mothers in that market segment also mentioned that their child not agreeing to be vaccinated was a barrier. This implies the need to provide mothers with the skills to communicate the benefits and importance of vaccination along with how to address their child's concerns.
• Place: Overall, the researchers found that the clinic (community communication method) was, by far, where most mothers in both market segments heard about the HPV vaccine for the first time and made the initial decision to vaccinate. The child's school, another community communication method, emerged as the second best place to encourage these mothers to have their children complete the series. Other communication methods that emerged included: television (public/mass communication method), friends and relatives (both interpersonal communication methods), and the newspaper (community communication method).
• Promotion: The findings provide guidance for interventions regarding which sources Hispanic mothers prefer and trust. By far, both market segments will seek information about the HPV vaccine from the clinic, followed by child's school and community centre. The internet, by mail, television, and brochures were the preferred public/mass communication methods of promotion. The telephone was the only interpersonal communication method mentioned. Some Initiated mothers did not know where to seek information, unlike Completed mothers, who appear certain of where to seek information. As such, it is important provide mothers with details and options about where they can go to receive trusted information about the HPV vaccine. Clinic personnel should also be prepared to provide accurate and understandable HPV vaccine information for this population. The use of multiple communication methods to disseminate messages will potentially increase the salience of and reinforce the importance of HPV vaccine completion.

In short, the findings highlight the importance of removing informational barriers along with the central role of the clinic and clinic personnel in ensuring that adolescent Hispanics complete the HPV vaccine series.