The Development of a Culturally Relevant,Theoretically Driven HPV Prevention Intervention for Urban Adolescent Females and Their Parents/Guardians

Abstract

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, accounting for the large majority of cervical cancer and anogenital warts cases. Two HPV vaccines are currently licensed and recommended for women and girls. However, vaccination rates have been suboptimal, with evidence of disparities influencing both uptake and series completion among African American and Hispanic adolescents. There has been a dearth of theory-based, behavioral interventions targeted to prevent HPV infection and increase HPV vaccine uptake among urban adolescents. This article describes the development of two skills-based intervention curricula aimed to increase HPV prevention and vaccination among low-income urban adolescent females 9 to 18 years old. Guided by the theory of planned behavior, elicitation research was conducted to elucidate the social psychological factors that underlie HPV vaccination intentions (N = 141). The findings were subsequently used to identify theoretical mediators of behavioral change to drive the intervention. Culturally relevant strategies to promote HPV vaccination were translated into the curricula content. Both curricula were designed to motivate and empower participants to reduce risk of being infected with HPV. Targeting theoretical mediators of behavioral change, derived from the voices of the community, may prove to be successful in increasing HPV vaccination and preventing HPV.

Keywords

behavior change child/adolescent health community intervention immunization minority health sexual health

Introduction

Nearly 6 million Americans contract human papillomavirus (HPV) annually; 74% are 15- to 24-year-olds (Weinstock, Berman, & Cates, 2004), making HPV the most common sexually transmitted infection (STI). The incidence of HPV among adolescents exceeds 60% in some studies (Brown et al., 2005). Low-income and racial/ethnic minority populations are disproportionately affected (Kahn, Lan, & Kahn, 2007). Sexual activity, early sexual debut, and multiple sexual partners increase HPV risk (Hariri et al., 2011). Forty-six percent of adolescent females report having had sex, and 36% are currently sexually active. These numbers are higher for Black adolescent females, 58% of whom report having had sex (Centers for Disease Control and Prevention, 2010). Hence, HPV prevention strategies for adolescent females are essential.

Background

One third of the more than 100 types of HPV cause genital infection (Castellsagué, 2008), whereas only 4 types cause 70% of cervical cancers (types 16 and 18) and 90% of anogenital warts (types 6 and 11; Munoz, Castellsague, de Gonzalez, & Gissmann, 2006). HPV is asymptomatic in about 40% of infected females (Castellsagué, 2008). Within 1 year of becoming sexually active, more than 25% of women may acquire HPV infection from their first partner (Winer et al., 2008). More than 90% of HPV infections resolve spontaneously (Elfgren, Kalantari, Moberger, Hagmar, & Dillner, 2000). Given the absence of symptoms and possibility of spontaneous HPV clearance, it is challenging to communicate the significance of this STI, especially to adolescents whose awareness of HPV may be low (Klug, Hukelmann, & Blettner, 2008).

Two HPV vaccines are approved by the U.S. Food and Drug Administration (Koulova et al., 2008). The quadrivalent vaccine (types 6, 11, 16, and 18) is nearly 100% effective in preventing cervical dysplasia and external genital lesions (Siddiqui & Perry, 2006). The HPV 16/18 vaccine is 90% effective in preventing cervical intraepithelial neoplasia (Keam & Harper, 2008). The vaccinations are given in three doses. The HPV vaccine, however, offers no therapeutic benefit for women already infected with HPV (Hildesheim et al., 2007). Thus, HPV immunization is recommended for girls aged 11 or 12, prior to sexual debut (Markowitz et al., 2007). However, less than half of U.S. females aged 13 to 17 have received at least one dose of the HPV vaccine (Stokley et al., 2009). Because of inconclusive data on the efficacy of one or two doses, full series completion is advised (Centers for Disease Control and Prevention, 2007).

Despite increased rates of HPV awareness, knowledge about HPV is still relatively low among adolescents (Caskey, Lindau, & Alexander, 2008). While national data show that vaccination rates for Black and Hispanic female adolescents are higher than for White adolescents (CDC, 2012), Black race and lower neighborhood educational attainment are associated with lower series completion (Chao, Velicer, Slezak, & Jacobsen, 2009). Predictors of HPV vaccine acceptance among Black adolescent females include insurance coverage for vaccination, belief that referent others endorse vaccination, increased perceived vulnerability to HPV, fewer perceived barriers to vaccination, greater expectations of vaccine efficacy against cervical cancer, and provider recommendations (Brewer & Fazekas, 2007; Conroy et al., 2009; Kahn et al., 2008). Thus, disparities in HPV vaccination rates might be overcome through interventions that focus on these predictors.

Providing information on the severity of HPV infection and potential benefits of HPV vaccination may increase knowledge and vaccine acceptability among adolescent females (Thomas, Stephens, & Blanchard, 2010; Wetzel et al., 2007) and their parents/guardians (Cox, Cox, Sturm, & Zimet, 2010; Davis, Dickman, Ferris, & Dias, 2004; Dempsey, Zimet, Davis, & Koutsky, 2006). Although these educational interventions can influence vaccine acceptability, none of these studies have provided comprehensive HPV risk reduction strategies or skills to negotiate vaccination with parents and health care providers. Since Black adolescent females are at heightened risk for HPV infection, and less likely to initiate and complete the HPV vaccine series, skills-based interventions are needed above and beyond educational interventions.

A dearth of theory-based, behavioral interventions exist that target HPV prevention among Black adolescent females. Thus, the purpose of this study was to design and implement a skills-based intervention to increase HPV vaccination rates among females aged 9 to18 years in five preselected urban neighborhoods in Philadelphia, Pennsylvania. The interventions separately targeted both adolescent females (13-18 years) and parents/guardians of girls aged 9 to 18 years. This article addresses the goal of eliminating the gap in racial health disparities through a description of the process and methods used to design the curricula of interventions targeting low-income African American adolescent girls and their parents/guardians to promote their uptake of HPV vaccination.

Method

Theoretical Framework

The intervention curricula were based on the theory of planned behavior (TPB; see Figure 1; Azjen, 1991). According to the TPB, HPV vaccination intentions are based on the following theoretical mediators: attitudes toward vaccination, subjective norms in relevant referent groups, and perceived behavioral control over decision making and vaccination. Studies demonstrate that these factors are predictors of mothers’ intentions to vaccinate their daughters (Askelson et al., 2010; Kahn et al., 2009) and young women’s intentions to be vaccinated (Stringer, Teitelman, Jemmott, & Ludmir, 2010). Based on success in other STI prevention programs (Jemmott & Jemmott, 2000; Jemmott, Jemmott, & Hacker, 1992; Jemmott, Jemmott, Hutchinson, Cederbaum, & O’Leary, 2008; Jemmott, Jemmott, & O’Leary, 2007), we developed interview, focus group, and survey questions to elicit the aforementioned theoretical mediators of HPV vaccination intentions. Through this process, we identified salient factors for vaccination intentions, as well as theory-based, culturally relevant, developmentally appropriate strategies to promote vaccination.

Figure 1

Theoretical Model Depicting the Impact of a Culturally Relevant, Theoretically Driven Intervention on Human Papillomavirus (HPV) Vaccination

Procedures

This study was approved by the University of Pennsylvania Institutional Review Board. We recruited convenience samples of adolescent females aged 13 to 18 years (n = 93) and parents/guardians of adolescent females aged 9 to 18 years (n = 48) from community organizations in Philadelphia. To understand both successful motivators/facilitators and barriers to HPV vaccination, previous HPV vaccination of the adolescent or daughter was not an exclusionary criterion. Informed consent was obtained from participants aged 18 years and older. Assent and verbal parent/guardian permission were obtained for adolescents younger than 18 years.

The study began with semistructured interviews to elicit participants’ attitudes and beliefs. We later discovered that focus group methodology would provide richer data for our study aims, as we sought information on language, culture, and topic consensus. Twenty-three adolescents and 3 parents/guardians participated in interviews, and 71 adolescents and 45 parents/guardians participated in semistructured focus group discussions (N = 141). Fewer parents/guardians participated because their data reached theoretical saturation earlier (Bradley, Curry, & Devers, 2007). Prior to the interviews and focus groups, participants completed a self-administered questionnaire on sociodemographics, knowledge and attitudes about HPV and the vaccine, health care experiences, and sexual behaviors (adolescents only). All study activities occurred at community organizations within participants’ neighborhoods, with adolescents and parents/guardians separated.

The study instruments were designed to assess theoretical mediators of behavioral change in accordance with the TPB (Azjen, 1991). Table 1 highlights the questions developed to assess participants’ knowledge, attitudes, subjective norms, perceived behavioral control, and intentions. Interviews and focus groups were audio recorded and transcribed. All participants received $20 cash and two public transportation tokens.

Table 1

Sample Elicitation Questions

Targeted Construct	Response Options
Knowledge	True, false, don’t know
A girl cannot get HPV if there is no penetration during sex
The HPV shot protects against most cases of genital warts
It is important to get all three HPV shots
Attitudes	5-point Likert-type, strongly agree to strongly disagree
Getting HPV infection is not a big deal
Even if I don’t like needles, it is important for me to get the HPV shot
It is important to have my parent or guardian’s OK before I get the HPV shot
Subjective norms	Multi-item selection (i.e., mother, sister, partner)
Who would be happy if you got the HPV shot in the next 3 months
Who would be unhappy if you got the HPV shot in the next 3 months
Perceived behavioral control
I could explain to my parent or doctor why I want to get the HPV shot in the next 3 months	5-point Likert-type, strongly agree to strongly disagree
I am able to get the HPV shot in the next 3 months	5-point Likert-type, strongly agree to strongly disagree
What would make it hard for you to get the HPV shot in the next months	Multi-item selection (i.e., not knowing enough)
Intentions
I plan to get the HPV shot in the next 3 months	5-point Likert-type, strongly agree to strongly disagree
I plan to talk to my parent or guardian about HPV and the HPV shot in the next 3 months	5-point Likert-type, strongly agree to strongly disagree
How likely is it that you will decide to get the HPV shot in the next 3 months?	5-point Likert-type, very likely to very unlikely

NOTE: HPV = human papillomavirus.

When data collection was completed, two community advisory boards (CABs), adolescent and adult, were established to provide feedback on intervention development and implementation. Additional details on the CABs’ roles are provided elsewhere (Baker et al., 2012). We reviewed our study findings and intervention plans with the CABs, and following their approval, the interventions were piloted with four independent samples of the target audiences. Based on process measures and feedback from pilot participants, the curricula contents were not changed.

Data Analysis

Qualitative and quantitative data were analyzed concurrently and integrated. Interview and focus group transcripts were analyzed through thematic content analysis to identify within- and across-group themes. We used a deductive coding structure with eight codes created from the TPB constructs: attitudes (what is good/bad about getting the HPV vaccine), normative beliefs (who would approve/disapprove of getting the HPV vaccine), control beliefs (how easy/hard would it be to get the HPV vaccine), and HPV vaccination intentions (I plan/do not plan to get the HPV vaccine). Data were analyzed by hand, and two coders mapped participant responses to each of the theoretical constructs. Survey data were entered in SPSS 16, and descriptive analyses were completed; open-ended responses from questionnaires were coded and tallied. Multiple team meetings were held for immersion in the data through simultaneous review of the audio recordings, transcripts, notes, and survey data.

Results

Sample demographics are outlined in Table 2. Participants were predominantly African American. Among adolescents, nearly 60% had sexual histories, with a mean age at first intercourse of 14.3 years (SD = 1.4). The majority of the predominantly female (93.5%) parent/guardian sample had at least a high school diploma or GED (general equivalency diploma; 80.5%) and an annual household income of less than $20,000 (65.9%), with an average of 3.5 (SD = 2.1) children per household.

Table 2

Demographic Characteristics of Elicitation Participants (N = 141)

Characteristic	%
Adolescent sample characteristics (n = 93)
Age in years; mean (SD)	15.3 (1.8)
Race
African American	94.4
Caucasian	3.3
Hispanic	1.1
Other	1.1
Last year of completed school
Less than 9th grade	38.7
9th grade	25.3
10th grade	21.3
11th grade	10.7
12th grade	4
Ever had sex	59.8
Age in years at first intercourse; mean (SD)	14.3 (1.4)
Ever tested positive for an STI	7.5
Friends have sex	92.5
Ever heard of the HPV vaccine	64.5
HPV vaccination status
Vaccinated	40.9
Not vaccinated	48.3
Unsure	10.8
Parent sample characteristics (n = 48)
Age in years; mean (SD)	41.1 (10.6)
Females	93.5
Race
African American	100
Educational attainment
Less than high school diploma/GED	19.5
High school diploma/GED	61
Some college	7.3
College degree	9.8
Graduate degree	2.4
Household income ($)
<20,000	65.9
20,001-40,000	18.2
40,001-60,000	11.4
>60,000	4.5
Number of children; mean (SD)	3.5 (2.1)
Daughter has a health care provider	89.6
Daughter visited a health care provider within the past year	73
Daughter received any vaccines since the age of 10	64.6
Health care provider never recommended the HPV vaccine for daughter(s)	67.4
Daughter’s HPV vaccination status
Vaccinated	25.2
Not vaccinated	64.6
Unsure	10.4

NOTE: STI = sexually transmitted infection; HPV = human papillomavirus; GED = general equivalency diploma.

Adolescents

The majority (64.5%) of adolescents had heard of the HPV vaccine. They expressed favorable attitudes toward HPV vaccination during the interviews/focus groups, stating that the vaccine could prevent cervical cancer and genital warts. Negative attitudes centered on the vaccine’s inability to prevent all HPV types, participants’ fear of needles, and uncertainty about side effects. Most reported that referent females would approve of HPV vaccination, whereas referent males would disapprove. In focus groups, adolescents reported that others would approve of their getting the HPV vaccine so that they could protect themselves against HPV, even if they were not sexually active, whereas those who would disapprove would think that the vaccine “puts a disease” in their body or that vaccination indicated current sexually activity. Factors that would facilitate HPV vaccination included more information about the vaccine and its side effects, social support for vaccination, a convenient location and process for vaccination (e.g., walk-in appointment with same-day vaccination), and full financial coverage for the vaccine series.

Several myths also emerged during focus groups, including beliefs that the vaccine protected against all STIs or that it caused HPV infection. Additionally, many adolescents lacked knowledge about Pap smears and proper condom use. Some had been taught that Pap smears “cleaned you out,” and most did not know how to use male condoms. Our predominantly African American sample reported that seeing only one racial/ethnic group in study recruitment materials gave the impression that nonminorities “don’t get [HPV].” They suggested that we incorporate diverse racial/ethnic groups on the intervention staff and in the study’s printed materials to eliminate impressions of racial targeting or stigmatization.

Parents/Guardians

The majority (81.3%) of parents/guardians had heard of the HPV vaccine. The mixed-gender groups shared similar findings to the adolescents; no gender differences were noted. Referent other approval and disapproval, including reasons for disapproval, mirrored what adolescents shared. Parents/guardians not only recognized potential benefits of the vaccine but also discussed parallel vaccination barriers. They also reported that detailed information and full financial coverage for the vaccine series would facilitate vaccination.

Parent-/guardian-specific concerns were that vaccination would be perceived as a “license” for their daughters to be sexually active. Uncertainty about vaccine safety because of media stories and beliefs that the vaccine could cause reproductive changes (e.g., premature menstruation) also emerged. The need to miss time from work to accompany daughters to appointments was a unique barrier. However, some reported that vaccinating their daughters would give them peace of mind since adolescents are sexually active at young ages.

Data Translation

Our elicitation research demonstrated that adolescents’ attitudes, normative beliefs, and perceived behavioral control all significantly explained their intention to get the HPV vaccine (r² = .42-.64, r² = .62-.79, and r² = .29-.37, respectively). Therefore, the overall objectives were to overcome negative cultural beliefs and bolster positive attitudes associated with HPV vaccination, while increasing skills and strategies to get the vaccine and decrease HPV risk. Six goals were established: (a) increase knowledge of and perceived vulnerability to HPV; (b) bolster positive attitudes and beliefs regarding the vaccine; (c) build perceived behavioral control (self-efficacy), intentions, and skills to obtain HPV vaccine; (d) increase skills and comfort in talking to parents and health care providers about the vaccine; (e) develop acceptable and achievable strategies for getting vaccinated; and (f) increase skills and strategies to reduce their risk for HPV. The goals of the parent/guardian intervention mirror those of the adolescent intervention but reflect their distinct role in considering HPV vaccination for their daughters.

The following salient factors uncovered during data analyses were used to increase HPV vaccination intentions and subsequent vaccination: pain belief (regarding needles), referent other reaction belief (that talking about HPV vaccination will make others upset or cause them to assume that adolescents are having sex), prevention belief (that the HPV vaccine prevents HPV infection), perceived behavioral control to negotiate vaccination, and perceived behavioral control to schedule an appointment and get the HPV vaccine. Once the curricula structure and content were solidified, we developed interactive activities to meet each module’s objectives. See Table 3 for the translation of the data into intervention activities.

Table 3

Schematic of the Process of Applying Theory to the Translation of Data Findings Into Intervention Activities

Finding	Theoretical Construct	Goal	Skill Needed	Objectives	Activity Example
Participants believed HPV vaccination was good because it could prevent HPV infection but identified several barriers to vaccination	Attitude (prevention belief)	Bolster positive attitudes and beliefs regarding the HPV vaccine	Increased knowledge and risk–benefit assessment	Highlight the benefits of the HPV vaccine to increase participants’ outcome expectancies about the positive aspects of the vaccine Acknowledge barriers to HPV vaccination to validate participants’ concerns Encourage participants to identify strategies to overcome those barriers relative to their individual contexts Intended outcome: Participants take ownership for the strategies, which will help motivate them to consider the HPV vaccine as a means of protection from HPV and the negative health consequences of HPV infection	Facilitator prompted participants to brainstorm benefits of the HPV vaccine, barriers to obtaining the HPV vaccine, and strategies for overcoming those barriers; possible responses, derived from the data, were provided in the curricula to guide the discussion Benefit: Can prevent cervical cancer and genital warts Barrier: The needle will hurt Strategy: Have someone that I trust go with me to the doctor (i.e., mother or friend) and know that the pain of the shot is temporary but the vaccine will protect me for years
Shared concern among all participants about referent others’ opinions about HPV vaccination and the assumption of current sexual activity	Subjective norm (referent other reaction belief)	Increase skills and comfort in talking to referent others about the vaccine	Negotiation and communication	Encourage participants to examine the responses others may give for not wanting them, or their daughters, to get the HPV vaccine Provide opportunities to practice responses to reasons others might give against HPV vaccination Intended outcome: Participants develop a series of responses, in their own language, which will better prepare them to discuss HPV vaccination with referent others	Facilitator prompted participants to brainstorm reasons others might give for not wanting them, or their daughters, to receive the HPV vaccine, followed by brainstorming responses to those reasons; possible responses, derived from the data, were provided to ensure accuracy of the information Reason: You’re not having sex, so why do you need the vaccine? Response: Whether I am having sex or not, I want to be responsible and do everything I can to protect myself
Some participants did not feel they had the control to get the HPV vaccine, or to get the vaccine for their daughters	Control belief (perceived behavioral control to negotiate vaccination)	Build participants’ perceived behavioral control (self-efficacy), intentions and skills to obtain HPV vaccine	Increased self-efficacy	Identify strategies to talk about getting the HPV vaccine Provide opportunities to practice such strategies during role-plays Encourage those not participating directly in the role-play to identify helpful strategies and coach those in the role-play Intended outcome: Participants increase their skills and feelings of confidence about HPV vaccination negotiation, as well as the likelihood that they will use these negotiation techniques in real life situations	Participants were taught to “C.H.A.T.” about the HPV vaccine and practiced the technique in role-playsAdolescents role-played talking to parents and guardians, and parents/guardians role-played talking to daughters and partners; topics for the scripted role-plays were derived from the data C = “Choose” to say yes to getting the vaccine H = “Have” an explanation for why you want to get the vaccine and the benefits of getting it A = “Assess” the steps for getting the vaccine T = “Talk” it out with your parent/guardian (daughter) and provider
Participants who had already received the HPV vaccine shared that they had experienced difficulty getting the vaccine and completing the series	Intention	Develop acceptable and achievable strategies for getting vaccinated	Navigation within the health care system	Promote realistic expectations of what getting the HPV vaccine will be like Identify potential system-level barriers to HPV vaccination (e.g., long wait times) Facilitate intention to vaccinate by helping participants fully understand all of the steps in getting the HPV vaccine Encourage participants to complete the vaccine series Intended outcome: Participants are prepared to successfully complete the HPV vaccine series	Participants were divided into two teams and given index cards that each had a step in completing the HPV vaccine seriesThe teams worked together to be the first to put the cards in order of the first through last step in the HPV vaccination processAmong the steps included were the following: getting information about the vaccine, seeing if the vaccine is covered by the insurance company, and setting a reminder for the final vaccine dose

NOTE: HPV = human papillomavirus.

To address the pain construct, the intervention included statements in participants’ own words about how needles hurt but the pain was only temporary, whereas getting genital warts or cervical cancer could last a lifetime. Furthermore, we appealed to the theme of social support for vaccination by encouraging participants to take a friend or relative with them to appointments; this also facilitated perceived behavioral control to schedule an appointment and get vaccinated. In one activity, participants were asked whether they agreed/disagreed with prevalent beliefs including: Girls can have unprotected sex (not use condoms) if they get the HPV vaccine and If my daughter gets the HPV vaccine it will give her the HPV infection. Participants were then asked to share why they agreed or disagreed with the statements, and the facilitator summarized the discussion with the factual response. To increase knowledge of Pap smears and condom use, we included information on pelvic exams and a condom use demonstration. For cultural relevance, we used direct quotes from elicitation participants, such as the difficulties in “raising teenage daughters this day and age” and the myth that “only ‘dirty’ [promiscuous] girls need to get the HPV vaccine.”

The Curricula

Elicitation participants were in favor of a group-level intervention. The curricula were optimized for use with 8 to 10 participants. The structurally similar content was designed to empower adolescent females and parents/guardians of adolescent females to reduce their/their daughter’s risk of being infected with HPV. The curricula: (a) address underlying attitudes and beliefs that many young women, or their parents/guardians, have about HPV and the vaccine; (b) provide information and skills-based exercises that teach proper condom use techniques and how to negotiate vaccination with others important in their decision-making processes; and (c) provide strategies for participants to navigate within the health care system. The themes for the curricula titles, “Help Yourself, Protect Yourself!” (adolescent version) and “Educate, Don’t Wait!” (parent/guardian version), were generated in the focus group discussions and are threaded throughout the interventions. Each curriculum has 2 hours of content divided into four, 30-minute modules, which are implemented in a single session (see Table 4). Both interventions were developed to facilitate easy dissemination and adoption in community settings, with minimal imposed resource burden. Electronic equipment was not required.

Table 4

“Help Yourself, Protect Yourself!” and “Educate, Don’t Wait!” HPV Vaccine Uptake Curricula

NOTE: HPV = human papillomavirus. C.H.A.T stands for “Choose” to say yes to getting the HPV vaccine, “Have” an explanation for why you want (your daughter) to get the vaccine and the benefits of getting it, “Assess” the steps for getting the vaccine, “Talk” it out with your parent/guardian (daughter) and provider.

“Help Yourself, Protect Yourself!”

Module 1 emphasizes knowledge, including the causes, transmission, detection, and prevention of HPV. Module 2 focuses on attitudes and beliefs about the HPV vaccine and HPV prevention and teaches skills for participants to either abstain from sex or use condoms correctly every time they have sex and to limit their number of sexual partners. Module 3 stresses the self-efficacy and communication skills necessary to get the HPV vaccine. Sensitive to parent/guardian concerns, we devoted considerable time to teaching communication and negotiation techniques for HPV vaccination. Philadelphia adolescents older than 13 years can receive HPV vaccination without parent/guardian consent, and public transportation allows independent navigation. Module 4 reinforces the skills of navigating the health care system and provides time for practice, support, and reinforcement of the session’s information.

This curriculum incorporates a series of fun, interactive activities designed to increase participation and help individuals understand factors that lead to HPV infection. Strategies include games, brainstorming, skill-building exercises, and minilectures that were designed to build group cohesion and enhance the learning experience. Specific activities include a scripted monologue to encourage participants to consider how easy it is to acquire HPV; images of the female reproductive system, cervical cancer and genital warts to depict the severity of HPV infection, as well as the steps in a pelvic exam; role-play scenarios to help participants build the confidence and skills necessary to negotiate vaccination and get the HPV vaccine; and practice navigating within the health care system such as scheduling appointments in advance and setting reminders. An educational brochure, which reinforced the curriculum content, was also developed for participants to take home. The brochure contained contact information for local HPV vaccine providers and a pocket-sized reminder calendar for participants to track their HPV vaccine doses.

“Educate, Don’t Wait.”

The parent/guardian curriculum uses similar activities as in the adolescent curriculum tailored to reflect parent’s/guardian’s language, attitudes, and beliefs. The modules address HPV susceptibility among daughters, while providing techniques needed to openly communicate with daughters and referent others about HPV vaccination, abstinence, sex, and condom use. Resources available for free vaccination, strategies to minimize burden associated with vaccination (e.g., lost time from work), and what to expect from the health care system were also addressed. Additionally, common and rare HPV vaccine side effects were distinguished to address vaccine safety concerns. Parents/guardians also received an educational brochure that paralleled the content of their curriculum.

Evaluation

To determine intervention effectiveness pretest, posttest, and 3- and 6-month follow-up surveys were developed. In line with the six intervention goals, evaluation measures assess: (a) knowledge of and perceived vulnerability to HPV; (b) attitudes and beliefs regarding the HPV vaccine; (c) perceived behavioral control, intentions, and skills to obtain the HPV vaccine; (d) skills and comfort in talking to parents and health care providers about the vaccine; (e) strategies for getting vaccinated and actual vaccination; and (f) sexual activity. The items mirror those in Table 1. The assessments for parents/guardians have the same questions but are related to their daughters’ vaccination and their own attitudes, beliefs, and knowledge about the vaccine.

Discussion

Two separate culturally relevant, theoretically driven HPV prevention interventions were developed for urban adolescent females and their parents/guardians. The majority of adolescents in our sample reported sexual activity before age 14. Thus, the population targeted for this intervention is at high risk for HPV. Given the long-term health implications of cervical cancer and genital warts, strategies to increase HPV vaccination rates are needed. Though adolescents are able to seek medical care independently in some communities, and demonstrate some autonomy in their health care decisions, it is also important to include parents in STI prevention initiatives.

We propose that the provision of knowledge in the absence of necessary skills to prevent HPV infection will both hamper HPV vaccine uptake and limit the impact on the transmission of other STIs. Therefore, in addition to the promotion of HPV awareness and education to increase vaccine acceptability, this intervention also provided participants with skills such as HPV vaccine negotiation, health care system navigation, and proper condom use. Another chief strength of the intervention is its adaptability and ease of implementation. Although the 2-hour time commitment may represent an obstacle to participation for some, the modular format provides flexibility to deliver segments of content at several sessions or to replace or modify content based on the desire to convey other important health messages. Schools, community-based organizations, family planning centers, and health educators linked to medical practices can easily implement the intervention as technical knowledge and expensive equipment are not required, and the curricula are written in a detailed, structured format that facilitates use with minimal training. Incentives may be required to facilitate participation, especially for parents who may require child care assistance; incentives may not be necessary, however, with the appropriate endorsement of respected community members or the integration of the curriculum into existing educational forums. Recommendations on how best to implement this intervention in nonresearch settings should await data evaluating its effect on HPV vaccination uptake, as well as the testing of modifications of the intervention to ascertain what segments are the most influential.

There are several limitations. Intervention development was almost exclusively informed by urban, African American adolescent females 13 to 18 years old or their parents/guardians. This population bias influenced content development and style. At the time this intervention was developed, the only approved HPV vaccine was indicated for females aged 9 to 26. Vaccination is now available for a wider age range of women and adolescent males. Some of the content of this intervention would not be suitable for older women or adolescent males. Our framework, however, can be used to understand the beliefs, attitudes, and norms that influence HPV vaccination intentions in these groups and populations in different regional/social/cultural contexts. In Pennsylvania, adolescents younger than 18 years may legally seek medical care related to their sexual health independent of their parents, including acquisition of the HPV vaccine. At times this may be of practical necessity, as many urban adolescents, including the majority that participated in this study, are raised by single, working mothers who are not always able to attend medical appointments. In communities where parents make all of the health care decisions for their daughters, there may be less of a need for an intervention that empowers adolescents. However, we believe that skills development around health care decision making will make adolescents better consumers of healthcare in the future. Last, participation in an intervention to influence adolescents’ or their parents’/guardians’ intentions to receive the HPV vaccine may not result in vaccination uptake. The availability of unbiased information on HPV vaccination, its endorsement by health care providers, and its availability at no cost or at an affordable price are other factors necessary to maximize HPV vaccination rates.

Conclusions

Health education interventions should be developed in partnership with the community to influence norms that affect behavioral objectives. The intervention development team created a culturally situated intervention that incorporated the language of our target population; addressed knowledge of and perceived vulnerability to STIs, including HPV; highlighted system-wide facilitators and barriers to HPV vaccination; and was feasible to disseminate in community settings. By targeting specific beliefs about HPV vaccination that came from the community for whom the intervention was designed, these interventions may prove to be successful in reducing the disparate burden of HPV among underserved and vulnerable populations.

Footnotes

Authors’ Note:

This work was supported by funding from the Pennsylvania Department of Health to Ian Frank.

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“Help Yourself, Protect Yourself!”	Time (Minutes)	“Educate, Don’t Wait!”
Module 1: Introduction to HPV: Acknowledging the Threat	30	Module 1: Introduction to HPV: Acknowledging the Threat
A. Welcome, Program Overview, and “Help Yourself, Protect Yourself!” Brainstorm	5	A. Welcome, Program Overview, and “Educate, Don’t Wait!” Brainstorm
B. Creating Group Rules and Guidelines	5	B. Creating Group Rules and Guidelines
C. Building HPV Knowledge: Acknowledging the Threat of HPV	20	C. Building HPV Knowledge: Acknowledging the Threat of HPV
Module 2: HPV Prevention	30	Module 2: HPV Prevention
A. The HPV Vaccine	5	A. The HPV Vaccine
B. Attitudes/Beliefs About the HPV Vaccine	10	B. Attitudes/Beliefs About the HPV Vaccine
C. Benefits of Abstinence and Condom Use Skills	15	C. Benefits of Abstinence and Condom Use Skills for My Daughter
Module 3: Barriers and Solutions for Obtaining the HPV Vaccine	30	Module 3: Barriers and Solutions for Obtaining the HPV Vaccine
A. HPV Vaccine: Barriers and Solutions for Obtaining the HPV Vaccine	5	A. HPV Vaccine: Barriers and Solutions for Obtaining the HPV Vaccine for My Daughter
B. “What to Say if My Parent/Guardian Says . . .”/Introduction to C.H.A.T.	10	B. “What to Say if My Daughter Says . . .”/Introduction to C.H.A.T.
C. Role-plays	15	C. Role-plays
Module 4: Enhancing Skills to Get the HPV Vaccine	30	Module 4: Enhancing Skills to Get the HPV Vaccine
A. HPV Vaccine Lineup: Navigating the Health Care System	10	A. HPV Vaccine Lineup: Navigating the Health Care System
B. Navigating the Health Care System Role-Play	7	B. Navigating the Health Care System Role-Play
C. HPV Basketball Game	8	C. HPV Basketball Game
D. Closing Activity/Talking About the HPV Vaccine: Information Review With the Adolescent Brochure	5	D. Closing Activity/Talking About the HPV Vaccine: Information Review With the Parent/Guardian Brochure