Acceptance of the HPV Vaccine in a Multiethnic Sample of Latinx Mothers

Abstract

This descriptive qualitative study explored Latinx mothers’ acceptance of the human papillomavirus (HPV) vaccine for their adolescent children. Data were collected through individual, semi-structured interviews and analyzed using a hybrid method of thematic analysis that incorporated deductive and inductive approaches. Twenty-two (n = 22), mostly foreign-born, Latinx mothers of male and female adolescents participated in the study. Three main themes and nine subthemes emerged from the analyses. Findings identified the need for increased efforts to raise awareness and knowledge among Latinx mothers of the direct benefits of the HPV vaccine for sons, including stressing prevention of HPV-associated cancers in males. Findings also underscore the need for improved health care providers’ communication and recommendation of the HPV vaccine for Latinx adolescent males. Future research should intervene upon the study’s findings to address barriers that remain and affect Latinx mothers’ acceptance and uptake of the HPV vaccine for their children, in particular their sons.

Keywords

human papillomavirus HPV vaccine Latino adolescent males females mothers qualitative research qualitative United States

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States (Jemal et al., 2013). An estimated 80 million people, about one in four adults in the United States, are currently infected with HPV and nearly 14 million people become newly infected each year (Jemal et al., 2013; Viens et al., 2016).

Latinx or Hispanics (hereafter referred to as Latinx) are expected to represent 30% of the U.S. population by 2050, and Latinx children currently account for one fourth of children below the age of 18 years (Pew Research Center, 2020). Evidence indicates that Latinx have higher incidence and mortality of some HPV-associated cancers than non-Hispanic Whites (Martinez Tyson et al., 2018). According to statistics from the Surveillance, Epidemiology, and End Results (SEER), in 2013, 9.4 in 100,000 Latinx women were diagnosed with cervical cancer compared with 7.5 in 100,000 non-Hispanic White women (Martinez Tyson et al., 2018). Latinx men had a rate of penile cancer that was 1.3 per 100,000 men compared with 0.7 per 100,000 men of all races (Martinez Tyson et al., 2018).

Vaccination is a safe and effective way to prevent HPV infection and HPV-associated cancers, conferring protection to the most common types of HPV that can cause cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers (Petrosky et al., 2015). The Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC), has recommended routine HPV vaccination at the age of 11 to 12 years for females, since 2006, and for males, since 2011 (Petrosky et al., 2015). Vaccination also is recommended for females, aged 13 through 26 years, and for males, aged 13 through 21 years, who were not vaccinated previously (Petrosky et al., 2015). The vaccination series can be started at the age of 9 years (Petrosky et al., 2015). HPV vaccines are administered as a 2-dose (0, 6–12 months) series, if vaccination is initiated at ages 9 through 14 years, and as a 3-dose series (0, 1–2, and 6 months), if initiated at ages 15 through 26 years (Petrosky et al., 2015). Despite evidence suggesting the effectiveness of the HPV vaccine as a cancer prevention strategy and evidence of increased vaccination rates among Latinx adolescents, uptake remains lower than the 80% goal set by Healthy People 2020 (n.d.). Moreover, studies suggest that Latinx adolescent males have lower rates of HPV vaccination than Latinx adolescent females (Roncancio et al., 2019; Suárez et al., 2019).

Although in the United States HPV vaccination is recommended, it is not mandatory across states (Petrosky et al., 2015; Pitts & Adams Tufts, 2013; Rendle & Leskinen, 2017). Therefore, parental acceptance, that is approval and agreement to the HPV vaccination, is central to improving vaccination rates (Bednarczyk et al., 2019; Petrosky et al., 2015). The health belief model (HBM) has been extensively used to understand factors contributing to parental acceptance and uptake of the HPV vaccine (Brewer & Fazekas, 2007). The HBM suggests that health prevention behavior is influenced by an individual’s perceptions of a threat posed by a health problem (e.g., susceptibility or severity), the perceptions of benefits of avoiding such threat (e.g., cancer prevention), and the factors influencing the decision to act (e.g., HPV vaccine initiation and completion; Brewer & Fazekas, 2007). Furthermore, the HBM posits that individuals may act on a new health prevention behavior when the perceived benefits (e.g., cancer prevention) outweigh the barriers of adopting such behavior (e.g., HPV vaccination).

Guided by the HBM research conducted among Latinx finds that maternal acceptance and uptake of HPV vaccination is influenced by a perceived risk of HPV infection and its consequences, and perceived benefits of the HPV vaccine (e.g., prevention of cervical cancer for daughters; Morales-Campos et al., 2018; Perkins et al., 2010, 2013; Roncancio et al., 2019). Factors such as beliefs that vaccination may promote adolescent sexual activity, religious beliefs, belief of child being too young and thus no immediate perceived need of vaccination, lack or inadequate knowledge about HPV and the HPV vaccine, concerns about vaccine safety and cost, and so on, have been found to influence parental acceptance and uptake of HPV vaccine (Bodson et al., 2016; Kepka et al., 2015; Morales-Campos et al., 2018; Roncancio et al., 2019; Vanslyke et al., 2008; Warner et al., 2015). Within the Latinx family, some studies indicate that parents also have misperceptions about risk of disease and direct benefits of the vaccine for males (Bodson et al., 2016; Kepka et al., 2015). Social norms have also been found to limit the acceptance of the vaccine’s benefits, especially for males (Casillas et al., 2011; Katz et al., 2016; Perkins et al., 2013). In addition, acculturation has been found to influence parental awareness and knowledge, beliefs, and attitudes toward the HPV vaccine (Bodson et al., 2016; Kepka et al., 2015). Furthermore, studies with Latinx parents point to inadequate recommendation of the HPV vaccine by health care providers, including at appropriate ages, sex differences, and economic status (Katz et al., 2016; Perkins et al., 2013).

Despite parents’ shared health decision-making for their children, mothers in particular are central to HPV vaccination as they are often the parent taking their children to health care visits (Parra-Medina et al., 2015; Roncancio et al., 2019). In the Latinx culture, mothers are seen as the child primary caretaker and responsible for caring for children’s health and taking their children to health care visits (Morales-Campos et al., 2018; Parra-Medina et al., 2015). In light of the confluence of these factors, the purpose of this study was to explore (a) Latinx mothers’ acceptance of the HPV vaccination for their adolescent children, and (b) suggest strategies to promote vaccine uptake among Latinx parents.

Method

Study Design and Sample

Qualitative research can offer insights into the question of “why” people engage in particular actions or behaviors (Patton, 2001). A qualitative approach is well-suited to understand how individuals interpret the world around them and how they construct meanings, generate motives, and develop relationships (Patton, 2001). In the present study, a descriptive qualitative design was chosen as it allows for a comprehensive summary (facts and meaning of facts) of the phenomenon of interest, that is, Latinx mothers’ perceptions, experiences, inclinations, sensitivities, and sensibilities related to acceptance of the HPV vaccine (Sandelowski, 2000).

Latinx mothers were recruited for in-depth, semi-structured qualitative interviews between November 2018 and February 2019 from several communities with large Latinx populations in the Greater Boston area of Massachusetts. Eligible mothers (a) had at least one child aged 11 to 19 years, (b) self-identified as Latinx, (c) lived in Massachusetts, and (d) if foreign-born, had lived in the United States for at least 12 months. We used convenience sampling techniques to identify Latinx mothers, which included (a) posting flyers in local Latinx businesses and community-based social and health services agencies, and (b) making announcements and using visibility strategies at predominantly Spanish-speaking churches (Lindsay, Delgado, et al., 2020; Lindsay, Pineda, et al., 2020). Participants also were recruited using a snowball sampling method that involved two approaches: (a) leveraging the personal and community networks of the Latinx research staff to recruit potential participants, and (b) asking early enrollees to recommend their eligible Latinx friends (Faugier & Sargeant, 1997; Lindsay, Delgado, et al., 2020; Lindsay, Pineda, et al., 2020).

Data Collection

We chose to conduct semi-structured interviews as they allow for the collection of valuable and in-depth information in diverse cultural settings (Peters & Halcomb, 2015). This protocol permitted mothers to provide sensitive perspectives regarding their experiences in vaccinating their adolescent children against HPV (Peters & Halcomb, 2015). A semi-structured interview instrument ensured that similar topics were discussed with all participants (Peters & Halcomb, 2015). These open-ended questions elicited participants’ perceptions and understanding of HPV infection, HPV-associated cancers, and the HPV vaccine as well as their personal experience with vaccinating their adolescent children (Katz et al., 2016; Lindsay, Delgado, et al., 2020; Roncancio et al., 2019). In addition, interviewers asked follow-up questions and used targeted probes to clarify responses and/or collect additional relevant information based on information shared by each participant. The instrument was piloted-tested with two Latinx mothers and the results of these interviews helped refine the instrument.

The interview instrument also included questions on participant’s sociodemographic information and acculturation level. The Short Acculturation Scale for Hispanics (SASH) assessed acculturation (Marin et al., 1987). The SASH assesses language use, media use, and ethnic social relations. Responses are measured on a scale of 1 to 5 (1 = least acculturated, 5 = fully acculturated) and an acculturation score averages the 12 items (Ellison et al., 2011; Marin et al., 1987).

All interested individuals were screened either in person or through telephone. Those meeting the eligibility criteria were invited to participate in the study. Written and verbal informed consent was obtained from all participants. Semi-structured, one-on-one interviews with eligible participants were conducted either at participant’s homes, private offices at the academic institution, or in public settings, including libraries or coffee shops.

Interviews were conducted by three Latinx members of the research team (M.J.V., D.D., and E.R.) with training in qualitative interviewing (Lindsay, 2020). A trained, bilingual (native Spanish–English speaker) research assistant (M.J.V.) took notes during all interviews. All mothers chose to be interviewed in Spanish. The interviews were audio-recorded after obtaining verbal consent from participants and lasted approximately 25 to 35 minutes. Participants received a US$25 gift card for their participation.

Data Analysis

Data collection and preliminarily data analysis were undertaken concurrently (Patton, 2001). The interviewer and research assistant met for about 20 minutes after each interview to discuss recurring themes and identify new additional themes. All audio-records were transcribed verbatim in Spanish by a professional, native Spanish-speaking transcriptionist (Patton, 2001).

Each transcript was anonymized, with the participant being given a number and any identifying data was removed. A qualitative descriptive approach was thematically used to analyze the transcripts (Sandelowski, 2000). Data were analyzed manually, using a hybrid methodology that incorporated an iteration of (a) deductive approach including a priori themes based on the interview guide and literature, and (b) data-driven inductive approach that allowed for new themes to emerge during analysis, thus expanding the possible a priori thematic categories (Patton, 2001).

Two authors (M.J.V. and D.D.), who are fluent in Spanish, independently analyzed the transcripts in Spanish using a multiphase process (Braun & Clarke, 2006). First, data were read thoroughly to acquire a basic understanding of the content, familiarization, and multiple readings of the transcripts. An iterative process of initial open coding was followed by selective and more detailed coding. Text that corresponded to the study’s purposes was divided into meaning units and condensed (i.e., shortened, but with the core message retained). The condensed meaning units were interpreted and labeled with codes to identify themes and patterns. Links and comparisons were made between themes, across participants, and with the broader literature (Braun & Clarke, 2006). Throughout an iterative coding process, the authors checked for coding consistency, discussed the codes, and resolved coding discrepancies. Finally, salient text passages were extracted and translated into English to illustrate emergent themes and subthemes (Patton, 2001). In addition, descriptive statistics were generated for the sociodemographic survey questions in Microsoft Excel 2008.

Ethical Considerations

The study was conducted according to the ethical principles described in the Helsinki declaration (World Medical Association [WMA], 2013). This study received ethical approval from the internal review board (IRB) at the University of Massachusetts Boston. Participants received information about the study, both verbally and in writing. Participation in the study was voluntary, and the participants were informed that they could withdraw at any time without stating any reason (WMA, 2013).

Results

Sample Characteristics

Table 1 shows that the sample consisted of 22 Latinx mothers of adolescent girls (~60%, n = 23) and boys (~40%, n = 15) between 11 and 19 years of age (mean age of adolescents = 15.3 years). The majority was married (76.8%, n = 16), and 40.9% (n = 9) reported having two children. Nearly all mothers were foreign-born (91%, n = 20), originating from Caribbean (Dominican Republic, n = 8), Central American (El Salvador, n = 4, and Guatemala, n = 4), or South American (Colombia, n = 4) countries. Approximately 46% of the mothers reported living in the United States for less than 10 years and about 91% (n = 20) reported lower acculturation levels (SASH <2.99).

Table 1.

Demographic Characteristics of the Sample (N = 22).

Variables	M (SD)	N (%)
Mother’s age	42.2 (6.3)
<40 years		7 (31.8)
≥40 years		15 (68.2)
Mother’s marital status
Single		2 (9.1)
Married		16 (72.8)
Separated/divorced		3 (13.6)
Missing		1 (4.5)
Number of children between 11 and 19 years of age
1		9 (40.9)
2		9 (40.9)
3		3 (13.6)
≥4		1 (4.5)
Children’s (11–19 years) gender
Male		15 (39.5)
Female		23 (60.5)
Son’s age^a	15.5 (1.8)
11–12 years		1 (6.7)
13–14 years		6 (40)
15–16 years		1 (6.7)
17–19 years		7 (46.6)
Daughter’s age^a	15.2 (2.4)
11–12 years		5 (21.7)
13–14 years		2 (8.8)
15–16 years		5 (21.7)
17–19 years		11 (47.8)
Son’s HPV vaccination status^a
0 doses		11 (73.3)
≥1 dose		4 (26.7)
Daughter’s HPV vaccination status^a
0 doses		1 (4.3)
≥1 dose		22 (95.7)
Son’ and daughter’s insurance status
Government-funded health insurance		37 (97.4)
Private health insurance		1 (2.6)
Mother’s educational level
Less than high school completed		9 (40.9)
High school completed		10 (45.5)
More than high school completed		3 (13.6)
Mother’s employment status
Employed		20 (90.9)
Unemployed		2 (9.1)
Household annual income
<US$40k		7 (31.8)
≥US$40k–<US$60k		15 (68.2)
Mother’s ethnicity
Hispanic/Latinx		22 (100)
Mother’s country/territory of origin
Colombia		4 (18.2)
Guatemala		4 (18.2)
El Salvador		4 (18.2)
Dominican Republic		8 (36.4)
United States		1 (4.5)
Puerto Rico		1 (4.5)
Mother’s number of years living in the United States^a
<10 years		10 (45.5)
≥10 years		12 (54.5)
Mother’s SASH score
<2.99		20 (90.9)
≥2.99		2 (9.1)

Note. HPV = human papillomavirus; SASH = Short Acculturation Scale for Hispanics.

Only those 11 to 19 years of age (i.e., age eligibility for study).

Nearly all mothers reported their adolescent children (n = 38), ages 11 to 19 years, as having government-sponsored health insurance (97.9%, n = 37). In addition, whereas mothers reported high uptake of the HPV vaccine for their daughters, with almost 96% (95.7%, n = 22) having received ≥1 dose of the HPV vaccine, uptake of the vaccine for their sons was low, with only about 27% (26.7%, n = 4) having received ≥1 dose of the HPV vaccine.

Themes and Subthemes

Figure 1 shows the three main themes and nine subthemes identified in the analyses. These themes and subthemes are discussed below, with illustrative representative quotes from participants.

Figure 1.

Themes and subthemes.

Theme 1: Perceived health risk related to HPV infection and perceived benefits of the HPV vaccine

Subtheme 1.1: High acceptance and initiation of the HPV vaccine for daughters but inadequate knowledge of multiple doses

Mothers reported high acceptance of the HPV vaccine for their daughters. All but one mother (n = 21) reported their daughters as receiving at least one dose of the vaccine (Table 1). There was consensus among mothers interviewed about the importance of and direct health benefits of vaccinating their daughters to confer protection against HPV infection and to prevent future risk of cervical cancer. One mother mentioned,

My daughters’ doctor mentioned during their check-up visit and told me about the vaccine and said it would prevent from developing cancer. I mean uterine cancer. My oldest, the 20 and the one that’s 17 had the vaccine. I think it’s important to protect them so in the future they don’t have uterine cancer.

Nonetheless, despite the higher initiation of the HPV vaccination, some mothers were unsure whether their daughters had completed the vaccine series. Some mothers appeared unaware of the required multiple doses for completion of the HPV vaccination. For example, one mother reported,

I didn’t know that she [daughter] needed to have another vaccination. To tell you the truth, I thought that she was done. At least the knowledge that I had was that it was only one vaccine dose. I did not know that I had to go back for other doses. I think perhaps her doctor will tell me later?! I am not sure. . .

Subtheme 1.2: Low acceptance and initiation of the HPV vaccine for sons and inadequate knowledge of multiple doses

In contrast, mothers reported lower acceptance of the HPV vaccine for their sons (n = 6). The majority of mothers (n = 16) did not perceive HPV infection as a significant risk for their sons’ health. Although mothers understood that adolescent males could become infected and transmit HPV, most mothers (n = 16) explained that they did not perceive direct health benefits of the vaccine such as prevention of future HPV-associated cancer for adolescent males as they did for adolescent females (i.e., cervical cancer). This was true for mothers who had only daughters, only sons, or daughters and sons. For example, one mother reported,

The way I understand men can have the papillomavirus like other infections and pass from having sex with many partners and without protection. They can have it just like women can also have sexual infections. But with the papillomavirus what I understand is that only women can develop cancer, uterine cancer, but not men. But they can have herpes, you know, and these types of infection from the virus. My two daughters had the HPV vaccine, but my son, he didn’t get it. . .

Only a few mothers (n = 6) believed in vaccinating boys against HPV for protecting their health. Moreover, although a few mothers reported acceptance of the HPV vaccine for their sons, some were unaware of the need for additional doses. One mother stated,

Well, they gave him only one [dose]. I don’t know if later, maybe. Given that he’s now 16, perhaps they will still give him another one? I have to ask his doctor to tell me if he needs it again. Like a renewal, I imagine. . . but he only had one.

Theme 2: Psychosocial and cultural influences on acceptance of the HPV vaccine

Subtheme 2.1: Parents are hesitant to talk to their adolescent children about the HPV vaccine

Many mothers expressed hesitancy in speaking with their children about the vaccine. They feared that to talk about the HPV vaccine would initiate conversations about sexuality and sexual health, which most mothers were uncomfortable with. While mothers recognized the importance of parents talking with their children about their sexual health, the majority spoke of the Latinx cultural taboo of parents talking openly about sexuality and sexual health with their children. One mother mentioned,

Look, to tell you the truth with [daughter’s name], my younger one I have not yet spoken with her. She knows only what we heard there [health clinic] with the doctor when she received the vaccine. And it is not like that she was “oh, this interested me!” But I have not spoken so seriously. Maybe her older sister speaks with her about these things. Maybe the older one does because she is the one who talks the most about things like this with her. But yes, it’s time to talk now. . . [sigh]

Subtheme 2.2: Religious beliefs

Although the majority of mothers reported believing in the importance of vaccinating their children, particularly their daughters, against HPV to protect their health (e.g., STI and future risk of cervical cancer), several mothers stated that, first and foremost, they entrusted their children’s health to God. Religious beliefs (i.e., fate, destiny, and God’s will) also were present in mothers’ descriptions of their own personal health experiences. A few mothers noted that they and their family members never had their health affected by HPV infection or HPV-associated cancers despite not being vaccinated. As one mother reported,

. . . the truth is that God is the almighty and he will protect those who cannot protect themselves. Our lives are in his hands. Look at some people who don’t have vaccines or good health care. Look in my country! We grew up poor. There was no vaccine for this cancer. Me, my sisters, my cousins, all, thanks to the Lord, we never had infections of this kind or uterine cancer in our family.

These mothers expressed the belief that “God is in control,” and that they were protected because of “God’s will.”

Moreover, a couple of mothers reported that cancer (e.g., cervical cancer) was a curse, and one could be cured only with God’s intervention. For example, one mother said,

Well, I don’t know if you can talk about it in this investigation [research], but the church has taught us that cancer or any disease has to be canceled by one’s faith in God because it comes inherited with our families. It’s like something that we don’t know how, but we were given. So, when we come to Christ, we have to say the names of the relatives and if I belong to the Martínez family, I say, I cancel all cancers of my family, of my ancestors. Because it says that it continues until the fourth generation, all curses. Because those are generational curses of diseases. . .

Subtheme 2.3: Influence of family members

The majority of mothers mentioned that despite their belief in the importance of vaccinating their children against HPV, the opinion of family members (e.g., husbands, grandparents, and elder siblings) weighed on their decision-making. Several mothers cited their concerns over family members’ beliefs that the vaccine was to prevent an STI and that they could not imagine their 11- and 12-year-old children being sexually active or, in some cases, family members believing that the vaccine would promote sexual disinhibition and early sexual activity. These concerns were especially true for daughters. One mother mentioned,

I think that the vaccine is important and will protect my daughter. I personally trust her and the education we give her at home. But not everyone in my family sees the same way. I have to listen to her father, his mother, my mother-in-law, and also my eldest [son]. They don’t see why she needs the vaccine because she is very young. So, I try to explain that the vaccine is to prevent for the future. It’s not that I think she’s having sex. But they don’t see the same way . . .

Subtheme 2.4: Influence of social networks

Social networks also emerged as important influences on mothers’ beliefs and acceptance of the HPV vaccine. In contrast to the influence of family members, most mothers stated that their friend networks were supportive of the HPV vaccine. For example, mothers reported their friends providing information, affirming the importance of the vaccine, sharing their personal experiences of vaccinating their children, and, in some cases, lessening concerns that mothers might have had about vaccinating their adolescent children. For example, one mother mentioned,

I already knew a little bit about the vaccine before the doctor told me to give it to my youngest son. A couple of friends, and also my cousin in Ecuador, they have older children and they said it was good to give the vaccine to my son. They said not to listen to some people who you know, like to say that the vaccine is no good, and about children starting to have sexual relations early and these sorts of things.

Nonetheless, a few mothers reported their friends’ negative beliefs about the HPV vaccine influencing their views or casting doubts about the vaccine. One mother said,

A friend of mine said, “Why did you let her take that [vaccine]? Because I was told that it doesn’t work.” So, I didn’t pay much attention to it, but then my other friend told me the same thing, “Hey, why did you let them give that to your daughter? That’s not good.” But what do I know? I trusted her doctor.

Theme 3: Health care providers’ influential role on uptake of the HPV vaccine

Subtheme 3.1: Inadequate health care provider’s recommendation of the HPV vaccine for adolescent males

Across all interviews, mothers overwhelmingly reported the positive influence of health care providers’ recommendations on their uptake of the HPV vaccine for their adolescent children. Whereas all mothers reported their health care provider recommending the HPV vaccine for their daughters, only a few mothers (n = 5) recalled receiving a recommendation to vaccinate their sons. One mother said,

For boys I don’t believe it’s needed. I could not tell you why, but I do not think so. I can’t remember ever hearing about boys getting this vaccine. I have never been told for my son that he needed the vaccine. So, I don’t think it’s for boys because otherwise the doctor would have told me, right?!

Subtheme 3.2: Long-term and trusting relationship with health care provider

The majority of mothers explained that having a long-term and trusting relationship with their child’s health care provider was critical in assuring them of the importance of vaccinating their children against HPV. Mothers also attributed having such relationship lessening their concerns about the vaccine’s safety and potential side effects. One mother mentioned,

Since they [children] were born she was the only doctor who has attended them, and she is their doctor until now. The boy now is too old and goes to another clinic. But I like her and trust her a lot my daughters’ doctor. She always tells me when they need vaccines and explains everything. She asks if I have questions. I’ve always given them all the vaccines she tells me they need. If she [doctor] tells me they need it, it’s because they really need it and I trust her. . .

Subtheme 3.3: Health insurance

Having health insurance also emerged as an important influence on mothers’ uptake of the HPV vaccine. Several mothers mentioned that not having to worry about vaccination cost facilitated their prompt uptake of the vaccine upon recommendation of their child’s health care provider. As one mother stated, “. . .Financially it is not a problem to give them the vaccine because we do not pay because the insurance pays. So, it is not difficult because we don’t have to pay . . .”

Discussion

This qualitative study explored Latinx mothers’ acceptance of the HPV vaccine for their adolescent children. Findings revealed mothers’ higher acceptance of the HPV vaccine for their daughters and their positive beliefs about the direct benefits of the vaccine to protect their daughters’ health by preventing STI and future cervical cancer risk. Such positive beliefs influenced mothers’ higher uptake and initiation of the vaccine for their daughters. In contrast, study findings revealed mothers’ low acceptance and uptake of the vaccine for their sons. Our findings showed that the majority of mothers did not perceive HPV infection as a major risk to their sons’ health and, therefore, did not perceive direct health benefits of the HPV vaccine for their sons as they did for their daughters (i.e., prevention of cervical cancer). These findings are supported by prior research, suggesting that mothers are more likely to perceive disease risk, direct benefit of the vaccine, and consequently more willing to vaccinate their daughters than their sons (Katz et al., 2016; Lindsay, Delgado, et al., 2020; Niccolai et al., 2016; Roncancio et al., 2019). A systematic review by Holman et al. (2014), including 55 studies, found that parents’ preference to vaccinate females over males was reported by the majority of studies. More recent studies with multiethnic populations (Joseph et al., 2012; Lee et al., 2018; Rendle & Leskinen, 2017) and also Latinx (Perkins et al., 2013; Roncancio et al., 2019) have documented that parents of adolescent males report not vaccinating their sons because of the lack of perceived direct health benefit of the vaccine for males. Our findings, similar to other research, emphasize the need for renewed efforts to increase parents’ awareness and knowledge of HPV-associated cancers that affect both males and females and the direct cancer prevention benefits of the HPV vaccine for males (Holman et al., 2014; Lindsay, Delgado, et al., 2020; Perkins et al., 2013; Roncancio et al., 2019; Suárez et al., 2019). These efforts are likely to contribute to increasing HPV vaccination rates for Latinx adolescent males.

The vast majority of mothers participating in this study reported Spanish as their primary language and had low acculturation levels. Previous studies conducted with Latinx have highlighted the influence of acculturation on parents’ acceptance of the HPV vaccine and the importance of tailoring the design of interventions to parents’ acculturation levels (Galbraith et al., 2016; Kepka et al., 2015). For example, Kepka et al. (2015), in a cross-sectional study of 67 Latinx parents in Utah, found that low-acculturated parents were more likely than high-acculturated parents to report inadequate information about HPV and the HPV vaccine, including not knowing multiple required vaccine doses and the direct benefits of the HPV vaccine for adolescent males. Our findings, combined with that of previous research, emphasize the need for interventions targeting Latinx parents with lower acculturation levels to incorporate culturally targeted materials to increase parents’ knowledge of risk of HPV-associated cancers and the direct benefits of HPV vaccination for both sons and daughters (Galbraith et al., 2016; Kepka et al., 2015).

Moreover, several psychosocial and cultural factors, such as religious beliefs and interpersonal relationships (e.g., family members, social networks) emerged as essential influences on mothers’ acceptance and uptake of the HPV vaccine for their adolescent children. Similar to prior research with other racial and ethnic minority (Joseph et al., 2012; Lee et al., 2018) populations including Latinx (Katz et al., 2016; Perkins et al., 2013; Roncancio et al., 2019), our findings suggest understanding and taking into account multiple psychosocial and cultural factors when designing interventions to promote uptake, initiation, and completion of the HPV vaccination among Latinx parents. Targeted interventions for Latinx should integrate cultural and religious beliefs and the influence of parents’ interpersonal networks. Efforts to promote HPV vaccination among Latinx may benefit from partnerships with and collaboration from religious/spiritual organizations.

Our findings extend those of previous research on the critical influence of health care providers’ recommendation of the HPV vaccine on parents’ uptake of the HPV vaccine for their adolescent children (Galbraith et al., 2016; Niccolai et al., 2016; Perkins et al., 2013). Mothers participating in our study unanimously reported that the health care provider’s recommendation was a significant influence on their uptake of the HPV vaccine. Nonetheless, it is noteworthy that whereas all mothers of adolescent females reported receiving a recommendation to vaccinate their daughters against HPV, only a few mothers of adolescent males reported receiving a provider’s recommendation to vaccinate their sons. This concerning finding is consistent with prior research with other racial minority and ethnic groups (Barnack-Tavlaris et al., 2010; Fenton et al., 2018; Gilkey et al., 2018; Nan et al., 2019; Shao et al., 2015), including Latinx (Galbraith et al., 2016; Perkins et al., 2013; Roncancio et al., 2019), which indicate that parents of unvaccinated sons are more likely than those of daughters to report not getting a physician’s recommendation or not being aware that the vaccine was available for their son. A recent systematic review found that the majority of included studies reported that providers were more likely to recommend the HPV vaccines to girls versus boys and older versus younger adolescents (Rosen et al., 2018). Combined with prior research, our findings highlight the importance of health care providers’ recommendation of the HPV vaccine. Most importantly, our findings underscore the need for continued efforts to improve providers’ recommendation of the HPV vaccine for adolescent males, which will likely result in increased vaccination coverage among Latinx adolescent males.

Strengths and Limitations

Strengths of the present study include the heterogeneity of the study sample, with Latinx mothers of Caribbean, North, Central, and South American backgrounds. Similar themes emerged across subpopulation groups, which strengthen the study’s findings. In addition, the study team members are bilingual and bicultural, and immigrant Latinx. As with any research, there are also limitations to this study. The findings are based on a small, convenience sample of Spanish-speaking, majority immigrant Latinx mothers with low acculturation levels. Therefore, these results may not be generalizable to English-speaking Latinx mothers, and those with high acculturation levels. Participants were recruited from urban communities in Massachusetts, a state with higher rates of government-sponsored health care coverage. Therefore, results may also not be generalizable to other populations in the United States. Furthermore, the use of snowball sampling may have led to the selection of participants who share similar beliefs, attitudes, and experiences. Despite the use of a semi-structured interview instrument and interviewers’ training, there is potential for interviewer bias.

In addition, our study included only mothers. Although evidence suggests that fathers may be less likely than mothers to be the parent to take their child to health care visits, it would be important to understand the role fathers play in the health care decision about vaccinating their children against HPV. Such information would provide a complete picture of the HPV vaccine decisions made by Latinx families (Suárez et al., 2019). Finally, we did not collect data on mothers’ cancer screening history, which has been associated with HPV vaccination among daughters and sons (Morales-Campos & Parra-Medina, 2017). Future research can build on our findings with other research designs and address these limitations by quantifying Latinx mothers’ awareness, knowledge, and acceptability of the HPV vaccine for their sons, as well as exploring and quantifying Latinx fathers’ awareness, knowledge, and acceptability of the HPV vaccine for their sons and daughters. This information will be relevant to the development of interventions tailored to meet the needs of Latinx parents and ultimately increase their children’s HPV vaccination rates.

Conclusion

Despite these limitations, the findings of the present study have important implications for the design of cancer education and prevention interventions. For example, study findings suggest several psychosocial and cultural factors that should be considered when designing interventions developed to promote uptake of the HPV vaccine among Latinx parents and adolescents. In addition, findings identified the need for increased efforts to raise awareness and knowledge among Latinx mothers of the direct benefits of the vaccine for their sons: cancer prevention benefits of the vaccine for HPV-associated cancers that affect not only females, but also males. Such efforts should be culturally tailored to parents’ acculturation levels. Finally, findings underscore the need for improved health care providers’ communication and recommendation of the HPV vaccine for Latinx adolescent males. Future research should intervene upon findings identified in this study to address barriers that remain and affect Latinx parents’ acceptance and uptake of the HPV vaccine for their children and, in particular, for their sons.

Supplemental Material

sj-docx-1-poi-10.1177_1049732320980697 – Supplemental material for Acceptance of the HPV Vaccine in a Multiethnic Sample of Latinx Mothers

Supplemental material, sj-docx-1-poi-10.1177_1049732320980697 for Acceptance of the HPV Vaccine in a Multiethnic Sample of Latinx Mothers by Ana Cristina Lindsay, Madelyne J. Valdez, Denisse Delgado, Emily Restrepo, Yessica M. Guzmán and Phillip Granberry in Qualitative Health Research

Footnotes

Acknowledgements

The authors thank the mothers who participated in the study as well as community-based agencies for support in recruitment efforts. Yessica M. Guzmán participated in this research as part of a faculty-mentored undergraduate research program called, Avancemos! Advancing Research Skills and Professional Career Opportunities in Health Sciences for Latinx Students, at the University of Massachusetts Boston designed to provide mentorship, research training, and professional career development skills for undergraduate Latinx students in health sciences. Madelyne J. Valdez participated in this research as part of a summer internship awarded by the University of Massachusetts Boston–Dana-Farber/Harvard Cancer Center Partnership for Advancing Cancer Health Equity funded by the National Cancer Institute (NCI—2U54CA156734-06A1). The findings and conclusion in this report are those of the authors and do not necessarily represent the official position of the University of Massachusetts Boston–Dana-Farber/Harvard Cancer Center Partnership for Advancing Cancer Health Equity or the National Cancer Institute.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ana Cristina Lindsay

Author Biographies

Ana Cristina Lindsay is an associate professor in the Department of Exercise and Health Sciences at the University Massachusetts Boston in Boston, MA, USA.

Madelyne J. Valdez was an undergraduate research assistant in the Department of Exercise and Health Sciences at the University Massachusetts Boston in Boston, MA, USA at the time of the conduct of this research.

Denisse Delgado is a Ph.D. Candidate in Public Policy at John W. McCormack Graduate School of Policy and Global Studies at the University Massachusetts Boston in Boston, MA, USA.

Emily Restrepo was an undergraduate research assistant in the Department of Exercise and Health Sciences at the University Massachusetts Boston in Boston, MA, USA at the time of the conduct of this research.

Yessica M. Guzmán was an undergraduate research assistant in the Department of Biology at the University Massachusetts Boston in Boston, MA, USA at the time of the conduct of this research.

Phillip Granberry is a lecturer in the Economics Department, College of Liberal Arts and a Research Associate at The Mauricio Gastón Institute for Latino Community Development and Public Policy at the University Massachusetts Boston in Boston, MA, USA.

References

Barnack-Tavlaris

J. L.

Reddy

D. M.

Swain

(2010). Predictors of parents’ willingness to vaccinate for human papillomavirus and physicians’ intentions to recommend the vaccine. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 20(1), 28–34. https://doi.org/10.1016/j.whi.2009.08.007

Bednarczyk

R. A.

Ellingson

M. K.

Omer

S. B.

(2019). Human papillomavirus vaccination before 13 and 15 years of age: Analysis of national immunization survey teen data. The Journal of Infectious Diseases, 220(5), 730–734. https://doi.org/10.1093/infdis/jiy682

Bodson

Warner

E. L.

Kepka

(2016). Moderate awareness and limited knowledge relating to cervical cancer, HPV, and the HPV vaccine among Hispanics/Latinos in Utah. Health Promotion Practice, 17(4), 548–556. https://doi.org/10.1177/1524839916640271

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Brewer

N. T.

Fazekas

K. I.

(2007). Predictors of HPV vaccine acceptability: A theory-informed, systematic review. Preventive Medicine, 45(2–3), 107–114. https://doi.org/10.1016/j.ypmed.2007.05.013

Casillas

Singhal

Tsui

Glenn

B. A.

Bastani

Mangione

C. M.

(2011). The impact of social communication on perceived HPV vaccine effectiveness in a low-income, minority population. Ethnicity & Disease, 21(4), 495–501.

Ellison

Jandorf

Duhamel

(2011). Assessment of the Short Acculturation Scale for Hispanics (SASH) among low-income, immigrant Hispanics. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education, 26(3), 478–483. https://doi.org/10.1007/s13187-011-0233-z

Faugier

Sargeant

(1997). Sampling hard to reach populations. Journal of Advanced Nursing, 26(4), 790–797. https://doi.org/10.1046/j.1365-2648.1997.00371.x

Fenton

A. T.

Eun

T. J.

Clark

J. A.

Perkins

R. B.

(2018). Indicated or elective? The association of providers’ words with HPV vaccine receipt. Human Vaccines & Immunotherapeutics, 14(10), 2503–2509. https://doi.org/10.1080/21645515.2018.1480237

10.

Galbraith

K. V.

Lechuga

Jenerette

C. M.

Moore

L. A.

Palmer

M. H.

Hamilton

J. B.

(2016). Parental acceptance and uptake of the HPV vaccine among African-Americans and Latinos in the United States: A literature review. Social Science & Medicine, 159, 116–126. https://doi.org/10.1016/j.socscimed.2016.04.028

11.

Gilkey

M. B.

Zhou

McRee

A. L.

Kornides

M. L.

Bridges

(2018). Parents’ views on the best and worst reasons for guideline-consistent HPV vaccination. Cancer Epidemiology, Biomarkers & Prevention: A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 27(7), 762–767. https://doi.org/10.1158/1055-9965.EPI-17-1067

12.

Healthy People 2020. (n.d.). U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion. https://www.healthypeople.gov/2020/about-healthy-people/how-to-use-healthypeople.gov/frequently-asked-questions

13.

Holman

D. M.

Benard

Roland

K. B.

Watson

Liddon

Stokley

(2014). Barriers to human papillomavirus vaccination among US adolescents: A systematic review of the literature. JAMA Pediatrics, 168(1), 76–82. https://doi.org/10.1001/jamapediatrics.2013.2752

14.

Jemal

Simard

E. P.

Dorell

Noone

A. M.

Markowitz

L. E.

Kohler

Eheman

Saraiya

Bandi

Saslow

Cronin

K. A.

Watson

Schiffman

Henley

S. J.

Schymura

M. J.

Anderson

R. N.

Yankey

Edwards

B. K.

(2013). Annual Report to the Nation on the Status of Cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)–associated cancers and HPV vaccination coverage levels. Journal of the National Cancer Institute, 105(3), 175–201. https://doi.org/10.1093/jnci/djs491

15.

Joseph

N. P.

Clark

J. A.

Bauchner

Walsh

J. P.

Mercilus

Figaro

Bibbo

Perkins

R. B.

(2012). Knowledge, attitudes, and beliefs regarding HPV vaccination: Ethnic and cultural differences between African-American and Haitian immigrant women. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 22(6), e571–e579. https://doi.org/10.1016/j.whi.2012.09.003

16.

Katz

I. T.

Bogart

L. M.

C. M.

Liu

Cox

J. E.

Samuels

R. C.

Chase

Schubert

Schuster

M. A.

(2016). Barriers to HPV immunization among Blacks and Latinos: A qualitative analysis of caregivers, adolescents, and providers. BMC Public Health, 16(1), Article 874. https://doi.org/10.1186/s12889-016-3529-4

17.

Kepka

Ding

Bodson

Warner

E. L.

Mooney

(2015). Latino parents’ awareness and receipt of the HPV vaccine for sons and daughters in a state with low three-dose completion. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education, 30(4), 808–812. https://doi.org/10.1007/s13187-014-0781-0

18.

Lee

Y. M.

Riesche

Lee

Shim

(2018). Parental HPV knowledge and perceptions of HPV vaccines among Korean American parents. Applied Nursing Research, 44, 54–59. https://doi.org/10.1016/j.apnr.2018.09.008

19.

Lindsay

A. C.

(2020). Avancemos! Building partnerships between academia and underserved Latinx communities to address health disparities through a faculty-mentored undergraduate research program. Health Promotion Practice. Advance online publication. https://doi.org/10.1177/1524839920953782

20.

Lindsay

A. C.

Delgado

Valdez

M. J.

Restrepo

Guzman

Y. M.

(2020). “I don’t think he needs the HPV vaccine cause boys can’t have cervical cancer”: A qualitative study of Latina mothers’ (mis) understandings about human papillomavirus transmission, associated cancers, and the vaccine. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education. Advance online publication. https://doi.org/10.1007/s13187-020-01824-z

21.

Lindsay

A. C.

Pineda

J. A.

Valdez

M. J.

Torres

M. I.

Granberry

P. J.

(2020). Central American immigrant parents’ awareness, acceptability, and willingness to vaccinate their adolescent children against human papillomavirus: A pilot cross-sectional study. International Journal of Environmental Research and Public Health, 17(8), 2869. https://doi.org/10.3390/ijerph17082869

22.

Marin

Sabogal

Marin

B. V.

Otero-Sabogal

Perez-Stable

E. J.

(1987). Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences, 9, 183–205. https://doi.org/10.1177/07399863870092005

23.

Martinez Tyson

Medina-Ramirez

Flores

A. M.

Siegel

Aguado Loi

(2018). Unpacking Hispanic ethnicity-cancer mortality differentials among Hispanic subgroups in the United States, 2004-2014. Frontiers in Public Health, 6, Article 219. https://doi.org/10.3389/fpubh.2018.00219

24.

Morales-Campos

D. Y.

Parra-Medina

(2017). Predictors of Human Papillomavirus Vaccine Initiation and Completion Among Latino Mothers of 11- to 17-Year-Old Daughters Living Along the Texas-Mexico Border. Family & community health, 40(2), 139–149. https://doi.org/10.1097/FCH.0000000000000144

25.

Morales-Campos

D. Y.

Snipes

S. A.

Villarreal

E. K.

Crocker

L. C.

Guerrero

Fernandez

M. E.

(2018). Cervical cancer, human papillomavirus (HPV), and HPV vaccination: Exploring gendered perspectives, knowledge, attitudes, and cultural taboos among Mexican American adults. Ethnicity & Health. Advance online publication. https://doi.org/10.1080/13557858.2018.1494821

26.

Nan

Daily

Richards

Holt

Wang

M. Q.

Tracy

Qin

(2019). The role of trust in health information from medical authorities in accepting the HPV vaccine among African American parents. Human Vaccines & Immunotherapeutics, 15(7–8), 1723–1731. https://doi.org/10.1080/21645515.2018.1540825

27.

Niccolai

L. M.

Hansen

C. E.

Credle

Shapiro

E. D.

(2016). Parents’ recall and reflections on experiences related to HPV vaccination for their children. Qualitative Health Research, 26(6), 842–850. https://doi.org/10.1177/1049732315575712

28.

Parra-Medina

Morales-Campos

D. Y.

Mojica

Ramirez

A. G.

(2015). Promotora outreach, education and navigation support for HPV vaccination to Hispanic women with unvaccinated daughters. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education, 30(2), 353–359. https://doi.org/10.1007/s13187-014-0680-4

29.

Patton

M. Q.

(2001). Qualitative research & evaluation methods (3rd ed.). Sage.

30.

Perkins

R. B.

Pierre-Joseph

Marquez

Iloka

Clark

J. A.

(2010). Parents’ opinions of mandatory human papillomavirus vaccination: Does ethnicity matter? Women’s health issues: official publication of the Jacobs Institute of Women’s Health, 20(6), 420–426. https://doi.org/10.1016/j.whi.2010.07.001

31.

Perkins

R. B.

Apte

Marquez

Porter

Belizaire

Clark

J. A.

Pierre-Joseph

(2013). Factors affecting human papillomavirus vaccine use among White, Black and Latino parents of sons. The Pediatric Infectious Disease Journal, 32(1), e38–e44. https://doi.org/10.1097/INF.0b013e31826f53e3

32.

Peters

Halcomb

(2015). Interviews in qualitative research. Nurse Researcher, 22(4), 6–7. https://doi.org/10.7748/nr.22.4.6.s2

33.

Petrosky

Bocchini

J. A.

Jr. Hariri

Chesson

Curtis

C. R.

Saraiya

Unger

E. R.

Markowitz

L. E.

, & enters for Disease Control Prevention. (2015). Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the advisory committee on immunization practices. Morbidity and Mortality Weekly Report, 64(11), 300–304.

34.

Pew Research Center. (2020). How the U.S. Hispanic population is changing.

35.

Pitts

M. J.

Adams Tufts

(2013). Implications of the Virginia human papillomavirus vaccine mandate for parental vaccine acceptance. Qualitative Health Research, 23(5), 605–617. https://doi.org/10.1177/1049732312470871

36.

Rendle

K. A.

Leskinen

E. A.

(2017). Timing is everything: Exploring parental decisions to delay HPV vaccination. Qualitative Health Research, 27(9), 1380–1390. https://doi.org/10.1177/10497323166644

37.

Roncancio

A. M.

Carmack

C. C.

Ward

K. K.

Vernon

S. W.

Muñoz

B. T.

Cano

M. A.

Cribbs

F. L.

(2019). Toward a model of HPV vaccine series completion in adolescent Hispanic males: Identifying mothers’ salient behavioral, normative, and control beliefs. Family & Community Health, 42(2), 161–169. https://doi.org/10.1097/FCH.0000000000000221

38.

Rosen

B. L.

Shepard

Kahn

J. A.

(2018). US health care clinicians’ knowledge, attitudes, and practices regarding human papillomavirus vaccination: A qualitative systematic review. Academic Pediatrics, 18(2S), S53–S65. https://doi.org/10.1016/j.acap.2017.10.007

39.

Sandelowski

(2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. https://doi.org/10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g

40.

Shao

S. J.

Nurse

Michel

Joseph

M. A.

Suss

A. L.

(2015). Attitudes and perceptions of the human papillomavirus vaccine in Caribbean and African American adolescent boys and their parents. Journal of Pediatric and Adolescent Gynecology, 28(5), 373–377. https://doi.org/10.1016/j.jpag.2014.11.003

41.

Suárez

Wallington

S. F.

Greaney

M. L.

Lindsay

A. C.

(2019). Exploring HPV knowledge, awareness, beliefs, attitudes, and vaccine acceptability of Latino fathers living in the United States: An integrative review. Journal of Community Health, 44(4), 844–856. https://doi.org/10.1007/s10900-019-00636-7

42.

Vanslyke

J. G.

Baum

Plaza

Otero

Wheeler

Helitzer

D. L.

(2008). HPV and cervical cancer testing and prevention: Knowledge, beliefs, and attitudes among Hispanic women. Qualitative Health Research, 18(5), 584–596. https://doi.org/10.1177/1049732308315734

43.

Viens

L. J.

Henley

S. J.

Watson

Markowitz

L. E.

Thomas

C. C.

Thompson

T. D.

Razzaghi

Saraiya

(2016). Human papillomavirus-associated cancers: United States, 2008-2012. Morbidity and Mortality Weekly Report, 65(26), 661–666. https://doi.org/10.15585/mmwr.mm6526a1

44.

Warner

E. L.

Lai

Carbajal-Salisbury

Garza

Bodson

Mooney

Kepka

(2015). Latino parents’ perceptions of the HPV vaccine for sons and daughters. Journal of Community Health, 40(3), 387–394. https://doi.org/10.1007/s10900-014-9949-0

45.

World Medical Association. (2013). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. Journal of the American Medical Association, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053

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