Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Oct 1.
Published in final edited form as: Ethn Health. 2023 Mar 27;28(7):1026–1040. doi: 10.1080/13557858.2023.2193360

HPV vaccination and cervical cancer screening promotion among Black individuals: social ecological perspectives from key informants interviews

Adebola Adegboyega a, Desmennu Adeyimika b, Obielodan Omoadoni c, Dignan Mark d
PMCID: PMC10522792  NIHMSID: NIHMS1907782  PMID: 36973897

Abstract

Objectives:

Rates of HPV infection and HPV-related cancers are elevated in the Black population of the US. Efforts to promote HPV vaccination and cervical cancer screening are important to reducing the cancer burden among Black populations. The purpose of this qualitative descriptive study guided by social ecological model (SEM) was to describe from the perspective of key informants, the challenges and opportunities for HPV vaccination and cervical cancer screening promotion among Black adults.

Design:

Twenty-three key informants participated in individual interviews over zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy prior to data analysis. Two qualitatively trained researchers analyzed the data using content analysis.

Results:

Participants were aged 50 ± 4.1 years, 12 were females, and 18 identified as Black. Participants included health care providers, teachers, church and community leaders. Themes included HPV and cancer literacy, influence of religion, health care provider recommendations, social and cultural influences, accessibility and availability of services, economic constraints, limited community resources, and HPV vaccine mandates.

Conclusions:

SEM factors contribute to low HPV vaccine uptake and cervical cancer screening and these factors need to be addressed. Interventions addressing SEM factors peculiar to Black populations may promote HPV vaccination and cancer screening in this population.

Keywords: Cancer screening, HPV vaccination, social ecological model (SEM), Black populations, key informants, interviews

Prophylactic HPV vaccination has been available since 2006 for adolescents; catch-up through age 26 and recommendations were recently expanded as optional for 27–45 years (Centers for Disease Control and Prevention 2022; Shi et al. 2014). Although vaccination provides primary prevention against HPV-related diseases, in the US, the national HPV vaccine uptake remains lower (54.5%) than the healthy people 2030 target to increase vaccination to 80% among adolescents aged 13–15 (Centers for Disease Control and Prevention 2022). In 2018, 44.7% of Black females compared to 57.9% White females aged 18–26 years received one or more doses of the HPV vaccine. While rates were 26.6% among Whites males and 29.4% among Black males (Boersma and Black 2020).

Black individuals are at higher risk for HPV infections and associated diseases than their White counterparts (McQuillan et al. 2017; Shi et al. 2014). The incidence, mortality, and survival rates of HPV-associated cancers differ by cancer type, sex, and race/ethnic group. Women had a higher incidence than men, except for the oropharynx site (Centers for Disease Control and Prevention 2022; Osazuwa-Peters et al. 2021). Black women have significantly higher cervical cancer incidence (8.2 versus 7.3 per 100,000 women) and mortality (3.3 versus 2.1 per 100,000 women) than non-Hispanic Whites (U.S. Cancer Statistics Working Group 2022). Blacks had a higher risk of death from anal/rectal squamous cell carcinoma, oropharyngeal squamous cell carcinoma and cervical carcinoma; and Hispanics had a higher risk of death from oropharyngeal squamous cell carcinoma than non-Hispanic Whites (Osazuwa-Peters et al. 2021).

Cervical cancer is preventable through prophylactic HPV vaccination and is treatable if found early through screening. Thus, cervical cancer screening and the HPV vaccine have the potential to reduce the cervical cancer burden of populations at risk. There is compelling evidence that getting screening regularly may find cancer when treatment is likely to work best (Centers for Disease Control and Prevention 2020). However, cancer screening uptake remains low among racial and ethnic minorities in the US, which puts Black women at risk for avoidable morbidity and mortality from cervical cancer (DeSantis et al. 2016). Thus, there is a need to increase efforts toward promoting HPV vaccine uptake, increase cervical cancer screening, and reduce cancer burden for this high-need group.

Previous studies among Black individuals have shown that limited knowledge about HPV, concerns about HPV vaccine safety, and lack of recommendation for HPV contribute to low HPV vaccination (Maness et al. 2016; Cunningham-Erves et al. 2018; Galbraith-Gyan et al. 2019). Also, lack of access to screening services, negative past health care experiences, lack of provider’s gender concordance, fear of cancer diagnosis, and lack of health literacy (Ince-Cushman et al. 2013; Nolan et al. 2014; Kayser et al. 2022) contribute to low cervical cancer screening uptake. These studies sought perspectives from Black individuals, however, to fully understand how to promote adherence to cancer preventive behaviors, researchers must seek perspectives from individuals that are knowledgeable about the challenges and opportunities available within the larger social ecological context. Guided by the social ecological model (SEM) (McLeroy et al. 1988), we focused on key informants to provide insight on this topic. Therefore, the purpose of this study was to describe challenges and opportunities for HPV vaccination and cervical cancer screening from the perspective of key informants using the SEM.

Methods

This was a qualitative descriptive study (Creswell and Poth, 2016), designed to gain perspectives of key informants on attitudes and beliefs of Black adults on HPV vaccine and cervical cancer screening.

Conceptual framework

The SEM, a framework that conceptualizes health, broadly guided this study on multiple factors that might affect health. Based on the relevance of SEM as a model for prevention, this framework was used to guide and frame data analysis. The SEM posits that an individual’s behavior is integrated in a dynamic network of intrapersonal characteristics, interpersonal processes, institutional factors, community features, and public policy (Elder et al. 2007). The framework is based on the premise that the support in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes (McLeroy et al. 1988).

Sample and eligibility criteria

The Institutional Review Board approved all research procedures prior to research commencement. Between October 2020 and January 2021, we recruited 23 key informants, based on their influence and engagement in the community. Key informants in a community are individuals qualified to provide general information and perspectives about issues. For this study, key informants were persons knowledgeable about their community health such as health care providers, church leaders, community leaders, and others. We included several key informants that were not part of the target population, but these individuals were chosen based on their expertise in health care, knowledge of community programs, and are service providers to the target populations. Key informants recruited for this study understand cancer control and prevention among Black community. These individuals have organizational roles and understand the local context as well as the group about whom information is being sought. Potential participants were identified using a combination of recommendations and snowball sampling. In snowball sampling, participants who have special expertise or insight are asked to recommend others who have a particular skill set or knowledge base (Patton 2014). Individuals aged 21 years and above, English speaking, who could provide insight to the issue under investigation were eligible to participate.

Recruitment and setting

The project staff identified potential key informants through referrals from the community health center and religious and local community organizations. Potential participants were contacted via information provided by their referral. All key informants were recruited from Lexington, Ky and its surrounding cities with heterogeneous population with 8% of the population identifying as Black (U.S. Census Bureau 2021). All research procedures were approved by the University Institutional Review Board (IRB number 55357) prior to research commencement. All participants contacted agreed to participate and completed informed consent prior to interview being scheduled. The key informants were offered a $20 gift card from a national retailer.

Data collection

We pretested the interview guide developed based on the aim of the study and previous literature with three participants and received feedback on clarity and relevance of the questions.

The interview guide was revised based on feedback from the pretesting. Interviews were held and recorded over Zoom, each lasting between 35 and 60 min. The interview sessions were facilitated by the first author (AA) and these sessions were guided with the semi-structured interview guide (see the Appendix), and appropriate probes. We reached theoretical saturation (Creswell and Poth, 2016) of key issues after 23 key informants were interviewed because new ideas cease to emerge during the last three interviews. Zoom audio recordings were uploaded to Otter.ai (https://otter.ai/home), a web-based transcription company and were professionally transcribed. Transcripts were reviewed for accuracy and a research staff corrected errors or missing data.

Data analysis

Using the content analysis technique, the second author (AD) began the line-by-line coding of the transcripts. Coding involved aggregating the data text into small categories of information and assigning a label to the code (Creswell and Poth, 2016). The first author (AA) then worked with (AD) to refine and define the codes, eventually developing a preliminary codebook, which allowed standardization of the content analysis. The codebook underwent an iterative procedure to refine the codes and identify emergent themes. Guided by the SEM, the themes were then categorized into overarching themes based upon the different relationships and dimensions of the SEM. In addition to the standardization of the codebook, the independent transcript coding by two researchers enhanced the verification of themes and an audit trail ensured the reproducibility of the findings (Speziale, Streubert, and Carpenter 2011). Finally, we conducted member checking to verify the interpretation of the data that were provided (Creswell and Poth, 2016). We contacted two members with our preliminary findings to solicit their views on the data interpretation. They agreed that the findings were reflective of their ideas.

Results

We interviewed 23 key informants including health care providers, community leaders, high school teachers, and church leaders. Twelve of the key informants were female and eighteen identified as Black. Key informants ages ranged from 35 to 64 years (mean 50 ± 4.1 years). Two key informants were physicians, six nurse practitioners, three pharmacists, three health department employees, four church leaders, and three high school teachers, and the remaining two were community leaders and longtime residents in the community. In line with the interview guide, themes consistent with the SEM were discussed. Table 1 summarizes participants’ characteristics.

Table 1.

Demographic characteristics of key informants (N = 23).

Variable Mean ± SD or frequency
Age (years) 50 ± 4.1
Gender
 Male 11 (47. 8%)
 Female 12 (52.1%)
Race
 Black 18 (78.3%)
 White 4 (17.4%)
 Asian 1 (4.3%)
Area of practice
 Physician 2 (8.7%)
 Nurse practitioner 6 (26.1%)
 Pharmacist 3 (13.0%)
 Health department staff 3 (13.0%)
 High school teacher 3 (13.0%)
 Church leader 4 (17.4%)
 Community leader 2 (8.7%)
Years in practice 13.8 ± 1.8
Open in a new tab

Intrapersonal factors

Intrapersonal factors are individual characteristics including knowledge, attitudes and beliefs that influence health and health behavior. Key informants described the influence of inherent individual characteristics on HPV vaccination and cancer screening among Black adults. Intrapersonal factors identified by key informants included HPV and cancer literacy, access to vaccination and screening services, and religious/personal belief or faith in God.

HPV and cancer literacy.

The key informants indicated that many in the Black community lack adequate information on HPV and its consequences. One of the interviewees explained, ‘There’s lack of understanding about what HPV is, how it is transmitted, how common it is, that it can cause not only cervical cancers and other cancers.’ (Nurse practitioner). Yet another key informant noted, ‘I think literacy plays a very key role on the information people get about cancer prevention … ‘ (Health department staff). Similarly, another key informant stated, ‘In my interactions, I would say they are knowledgeable about the prevention, even the risk, but they may lack the knowledge about the consequences of HPV later.’ (Nurse practitioner)

One physician described how shortened health care encounters may contribute to limited opportunity to discuss preventive behaviors such as HPV vaccination and cervical cancer screening. He noted, ‘ …. with decreasing amount of time during well visits, it has really affected the amount of anticipatory guidance that providers do.’

The key informants suggested the need to create more awareness on HPV vaccination and cervical cancer screening through community health fairs and presentations at various social groups in the community including churches, mosques, and other community-based programs. Key informants emphasized the need for health advocacy programs via social media and community wide informational sessions.

Influence of religion on preventive behaviors.

Key informants discussed that personal faith and belief in God’s healing power was a determinant of cancer screening engagement among Black individuals. One key informant stated, ‘It’s not in our characters as Black people to want to find out about the proper investigation of our health. God is our protector; we are always protected with prayer. We are protected, we are healed so sometimes people don’t go to the hospital until they almost down and out. it’s just like this is cultural, will I say cultural has become endemic in us.’ (Health department staff)

Another informant stated, ‘Religion influences people’s decision regarding healthcare or going to the hospital or taking medicine or vaccine. Religion is a very tough thing because people believe whatever they believe.’ (Community leader)

Similarly, one church leader emphasized the need to involve religious organizations in preventive efforts because of the influence of religion in shaping beliefs. He stated, ‘religious setting in itself is a very strong place where you get your encouragement, your strength, your point of the way you think, is where you get it from. And so, when you want to make decisions about what to do especially like screening, that will carry a weight on your decision. I think that’s why the church needs to be part of this kind of effort if you want to improve compliance.

Interpersonal factors

Interpersonal factors are social relationships that may affect HPV vaccination and cancer screening behavior. Social relationships such as extended family support, neighbors, and friends may influence an individual’s behavior. Some of the interpersonal factors that contribute to the uptake of HPV vaccination and cervical cancer screening among Black adults discussed by the key informants include health care provider recommendation and social influences.

Health care provider recommendation.

Key informants identified a lack of recommendation and counseling by health care providers as factors that may influence Black adults’ receipt of the HPV vaccination and cervical cancer screening. One key informant stated: ‘A lot of the counseling and things that you would like to do is not technically billable for your time, and it’s just a flaw of the current system; counseling time has to be written a certain way to be billable.’ (Nurse practitioner)

Key informants indicated that health care providers need to continue to provide preventive care recommendations and counseling for all patients. Several key informants discussed that the communication process about HPV vaccination, cancer, and cancer screening should be comprehensive, and presented in a way that participants would understand the importance of following through with the recommendations and allay fears and concerns about the process. One key informant stated, ‘If providers don’t initiate it in a compassionate, respectful way, I don’t see it necessarily happening. I think the responsibility falls on the provider to create an atmosphere that is conducive to sharing sensitive information.’ (High school teacher)

Key informants emphasized that it is pertinent for health professionals to use every contact opportunity with clients to advocate and recommend preventive care. One key informant stated, ‘Many patients do not come into the clinic for preventive services, but they come when they are acutely ill, and so the focus at such point is to treat the sickness.’ (Health department staff)

Several informants discussed that the mistrust in health care and fear of cancer screening diagnosis and its consequences have deterred Black adults from undergoing screening. One key informant stated, ‘I think that providers have a job to do when it comes to engaging the people in terms of discussion about importance of screening …. What can I tell the person about their risk, especially when it comes to the Black population, how can I gain their trust?’ (Nurse provider).

Social and cultural influences.

Key informants highlighted that positive social influences are crucial to improve vaccination uptake and cancer screening among the Black population. According to the key informants, Black individuals are usually influenced by their social network to undertake preventive behaviors such as cancer screening and HPV vaccination. For example, individuals would be more motivated to undergo cancer screening if their family members or friends encouraged them to screen or model the behavior. Specifically, the respondents noted that parents who are opposed to vaccination due to their beliefs may deter their children from getting vaccinated especially when the parents are the ones making the decision. One key informant noted, ‘If their families aren’t saying, hey, you need to do this, or their friends aren’t saying, hey, you need to do this, well, they will think why do I need to do it?’ (High school teacher). Another key informant noted, ‘If grandma is the guardian, for one of my patients, the older generation, I think, is less likely to consent for HPV vaccines. And yeah, I’m just trying to think of any no’s that I’ve had. And most of them have been grandmas who don’t want to believe their grandchildren are having sex ever, in the future.’ (Nurse practitioner).

Key informants discussed that it is important to educate the significant others on the benefits and importance of vaccination and screening. Such significant others and stakeholders include parents (especially mothers) of children eligible for the HPV vaccine, community and church leaders, and all stakeholders in the programming of HPV vaccine uptake and cancer screening. One key informant stated, ‘The church is a social gathering, we need to take advantage of that. Even though, it’s becoming increasingly difficult for church members to listen, it’s still an avenue to push through. I think that the church has a role to play to get members, or maybe sensitize members on the importance of cancer screening and other cancer prevention.’ (Community leader)

Organizational/institutional factors

Organizational/institutional are organization structures that constrain or promote preventive behaviors. Key informants discussed that economic factors, availability and accessibility were key contributors to HPV vaccination and cancer screening rates among Black adults.

Accessibility and availability of services.

Key informants discussed that the lack of accessibility and availability of preventive services at proximal and safe distance to patients may make it difficult to obtain services. The participants discussed that the lack of vaccination or screening services within the Black community setting is a challenge. There is a need to improve access to vaccination and screening through community sites and outreaches such as community centers, mobile vaccination, and screening centers. One pharmacist stated, ‘HPV vaccination program hasn’t been done in community settings as commonly as other vaccinations yet. It’s still very much you have to go to a health care facility.’ One high school teacher stated, ‘Organizing community-based programs and health outreaches you can do something through the local YMCA, or you can just do like health fair in a community center, a lot of people congregate there ….’

Economic constraints.

Key informants discussed that economic factors may influence access to preventive cancer screening and vaccination. Participants described how economic limitations might contribute to a lack of insurance and being under-insured. Black adults have competing demands and may not prioritize anything that may put strain on their already limited finances and the time available to them. One key informant stated, ‘Government at different levels must work on improving the socio-economic livelihood of the people, this will help create the needed psychological balance for their understanding of the underlining issues and be willing to take necessary actions.’ (Church leader) Another key informant stated, ‘The economic disparity among these groups’ fuels suspicion. In many Black communities, there is high level of poverty … what they think about is their daily needs.’ (Community leader)

Community factors

Community-level factors are resources, norms, relationships, and networks which exist among individuals, organizations, and groups. Our interviews revealed that community factors contribute immensely to issues related to the HPV vaccine and cervical cancer screening uptake by our target population. Factors identified include the absence of community resources to promote HPV vaccination and cancer screening.

Limited community resources.

Key informants cited limited community resources within the Black community as a factor that may hinder HPV vaccination and screening. One key informant noted, ‘A hungry man is an angry man. You have to deal with the economic and community situation of the Black population. If you go there and try to talk about vaccinations, they won’t pay you any attention because those issues are secondary.’ (Community leader)

Key informants shared concerns about the community trust in the government and health care. One of the interviewees explained, ‘Generally, they do not belief that the government may be on their side. They transfer the lack of trust in government into their health. Even when they are being provided useful information, the information may not be taken seriously because of lack of trust and many people fall through the crack.’ (Physician) One of the key informants discussed that mistrust is pervasive among racial and ethnic minority populations. Specifically, one nurse practitioner noted that the trust around HPV vaccination stems from a publication, which came out some years ago. ‘I think there is a mistrust of immunizations in this country. I think it has a lot to do with the false autism paper that was published a long time ago. I think that has been very pervasive in the minds of Americans. And even though it’s been proven over and over and over, and I counsel my patients about that, there are 1000s of papers published about that not having a link that, you know, it planted a seed of doubt.’

Public policy factors

Public policy factors are local, state, and federal policies and laws that influence HPV vaccination and cancer screening. Our interviews showed that public policy factors such as inconsistent legislations and policies contribute to HPV vaccine and cancer screening uptake by our target population. Two identified public policies are HPV vaccine mandate and program eligibility.

HPV vaccine mandate.

Key informants perceived HPV vaccine mandate as a facilitator to vaccine uptake while the absence of vaccine mandates contributed to vaccine hesitancy. One of the key informants noted, ‘I think some of the hesitancy is that it’s not required. And why is it not required? And honestly, I don’t know the answer to why it’s not required.’ (Nurse practitioner). Some key informants reported a perceived lack of trust in government policies as a hindrance to HPV vaccine uptake. The Tuskegee experiment was one of the contributory factors to this lack of trust. In the words of one of the interviewees, ‘People are still scared to take any vaccine; people still remember the Tuskegee experience. It is even affecting the covid-19 vaccine uptake …. some people are not sure what they are being given.’ (High school teacher).

Another policy issue that was discussed was the availability and eligibility for government-funded programs to promote access to free or reduced-cost cancer screening and HPV vaccinations.

Discussion

In this study, we explored from the perspective of key informants, the challenges and opportunities for HPV vaccination and cervical cancer screening among Black adults through an SEM lens. Data were collected on interpersonal, intrapersonal, organizational/institutional, community, and policy factors. Results from this study point to interventions that might promote vaccination and cervical cancer screening use among Black adults.

One of the major findings from this study was the recommendation that health care providers should do a better job in communicating effectively with patients about screening and HPV vaccination guidelines. Health care providers’ recommendation for HPV vaccination and cancer screening is an important determinant for uptake (Steinwachs et al. 2010; Ylitalo, Lee, and Mehta 2013; Gerend et al. 2016; Amuta-Jimenez, Smith, and Brown 2022). This finding is consistent with other studies that have shown that effective patient-provider communication is important in many areas of health care, including the receipt of preventive services and cancer screening (Underhill and Kiviniemi 2012; Lin et al. 2017). Health care providers can serve as a key source for health information by assessing patient eligibility and negotiating a course of action (Lafata et al. 2014). High-quality patient-provider communication can influence a patient’s willingness to follow through with cancer screening and vaccination recommendation. Health care providers should be more proactive in encouraging their patients to engage in cancer preventive behaviors through a multiprong approach such as tailoring communication to Black individuals’ health literacy and English proficiency. For example, research has shown that intervention with education, motivation, and appointment reminder components increased vaccine compliance among African American adolescent girls though the increase was not significant (p = 0.12) and the uptake was still lower than national averages again suggesting that more may be needed to truly effect change in behavior (DiClemente et al. 2015).

Furthermore, providing culturally and linguistically appropriate information to assist patients in making preventive health decisions may promote uptake among minority and underserved populations (Lin et al. 2017). Health care providers should leverage every opportunity to assess the individual risks of patients and recommend HPV vaccination and cancer screenings appropriately. A key component to providing preventive health recommendations and education for underserved and minority groups would involve a certain level of cultural humility. Cultural humility is defined as a process of being aware of how people’s culture can impact their health behaviors and in turn using this awareness to cultivate sensitive approaches in treating patients (Miller 2009). In addition, health care providers should be offered interventions to guard against implicit biases toward Black patients.

We found that access and cost to preventive services influence HPV vaccination and screening completion. Black adults will benefit from appointment time flexibility and schedules to accommodate their work schedules and other competing demands. Un- and under-insured Black individuals may benefit from low-cost programs as well as navigation assistance to connect with appropriate programs. Being insured increases consistency in health care visits, which may serve as cues for individuals to adopt healthy behaviors as well as to avoid risky ones (Gonzalez et al. 2012). Health care interaction may provide an opportunity to receive health provider’s recommendation for needed preventive services. However, delay and avoidance of routine care would lead to missed opportunities for the management of chronic conditions, receipt of routine vaccinations, or early detection of new conditions, which might worsen outcomes (Czeisler et al. 2020)

Religious beliefs shape Black individual’s decisions about preventative health services in general and influence seeking to follow-up care for a cancer diagnosis. Faith and religious practices play significant roles within the Black community and the impact of prayer in health, sickness, and healing are well identified. Historically, Black American churches have played central roles in the political and social progress of Black people in the US (Lincoln and Mamiya 1990). A recent study conducted in nine African American churches in South Los Angeles supports the feasibility and acceptability of promoting cancer screening in partnership with health ministries through the use of community health advisors (Maxwell et al. 2019). Faith and religious institutions may be a platform leveraged as means of promoting preventive health messaging and activities to promote HPV vaccination and cancer screening. Such platforms should be used to address any anecdotal beliefs among religious individuals to reduce cancer disparities among Black individuals. Religious practices and attendance may promote exposure to church norms (e.g. no smoking, moderation of alcohol, no premarital sex) that promotes healthy outcomes.

A supportive social community could model the right attitude toward the HPV vaccine and cancer screening uptake to the Black population. Social and cultural influences are important determinants for vaccination and cancer screening engagement among Black adults. Social and cultural influences may encourage engaging in preventive care such as HPV vaccination and cancer-preventative behaviors with others in one’s social circle. In addition, the availability of supportive social influence can alleviate barriers such as transportation and cost by providing material aids and services and, may serve as succor for stressful life events and an opportunity to engage in preventive health. In accord with this study findings, several studies noted that support from family and social networks seemed particularly consequential to cancer screening engagement (Rogers et al. 2017; Smalls et al. 2018). According to Colón-López and colleagues, negative vaccination experiences and stories disseminated via social media could lead to misinformation that may impact HPV vaccination uptake (Colón-López et al. 2021). When negative vaccination experiences stories get disseminated, individuals rely more on anecdotal, experience-based information than evidence-based information underscoring the role of social influences (Dubé, Vivion, and MacDonald 2015). In the digital age, the anti-vaccination movements are powerful and have the potential to reach and influence many individuals and contribute to vaccine hesitancy (Dubé, Vivion, and MacDonald 2015). Thus, researchers and other interventionists should disseminate health promotion programs via social media to counteract the negative information on social media.

The HPV vaccine school entry requirement has been identified as an evidence-based strategy to increase vaccination rates among school-age children and youths (Greyson, Vriesema-Magnuson, and Bettinger 2019). Most legislations, laws, and policies guiding health programs stem from government in most, if not all states. Just like some other vaccines, the administration of the HPV vaccine for the prevention of HPV-related cancers should be a requirement for eligible individuals (children especially). In terms of policy, key informants identified inconsistencies in laws, legislation, and policies as a major barrier to HPV vaccination. As of 1 July 2020, five US states or territories (Virginia, District of Columbia, Rhode Island, Puerto Rico, and Hawaii) have implemented the HPV vaccination as a requirement for school entrance for 11–12 years old school age children (National Conference of State Legislatures 2021). Currently, most states allow pharmacists to administer the HPV vaccine (National Conference of State Legislatures 2021). Uniformity of HPV vaccine mandate for school requirement across US states or territories may increase vaccination rates among Black population.

For cancer screening, there are federally funded Centers for Disease Control’s (CDC), National Breast and Cervical Cancer Early Detection Program (NBCCEDP), and the Title X National Family Planning Program to support cervical cancer screening (Fowler et al. 2017; Allaire et al. 2019). The Title X Family Planning Program supports the delivery of contraceptive and related preventive care to a population that is predominantly female, low income, un-insured, young, and racially and ethnically diverse (Fowler et al. 2017). The NBCCEDP operates in all 50 states to provide breast and cervical cancer screening to uninsured and under-insured low-income women. The program also provides resources to educate the public and health care providers about screening for breast and cervical cancer and connect underserved women with screening services (Allaire et al. 2019). Black communities will benefit from connection with programs that give access to free or reduced-cost cervical cancer screening or HPV vaccination. For example, navigator programs connecting Black individuals with health care resources and programs could increase routine health care visits, HPV vaccination, and cancer screening for this group.

Limitation

The small sample is not representative of the population and not generalizable to the entire population. However, we reached saturation with the interviews conducted and selected study participants that were knowledgeable about the topic and understood the local context as well as the target population.

Conclusion

Findings from this study highlight attitudes and beliefs of Black adults toward HPV vaccination and cervical cancer screening from the perspectives of key informants. The findings suggest strategies to improve the uptake of preventive behaviors to reduce HPV-related cancers among minority populations. Increase in HPV vaccination and cervical cancer screening rates can be achieved through improved awareness and knowledge at the interpersonal and intrapersonal level, raising awareness at the institutional and community level using the combination of community-based, age-specific programming and appropriate resource/personnel allocations. For the approaches to translate to desired change, it is important that the right governmental policies be implemented where and when applicable. Using community-engaged research with community partners should be a priority for developing interventions to increase HPV vaccination and cervical cancer screening for Black populations.

Several of the factors identified in our study have been reported in studies with Black individuals/patients. Such factors included reliance on religious practices, knowledge of cancer risk factors, provider recommendation, social network influence, attitudes, socio-economic factors, lack of trust, and cultural factors (Henderson et al. 2022; Sage et al. 2020). However, additional research is needed to further examine if there are differences and similarities between key informants’ and Black patients’ perspectives regarding HPV vaccination and cervical cancer screening.

This study showed that certain SEM factors contribute to low vaccine uptake and cervical cancer screening and these factors need to be addressed. Such factors include inadequacies of policies guiding health programs, vaccine administration mandate, addressing the community’s distrust, and community awareness campaign while considering the cultural context. Armed with findings from this study and related studies by our research team, using a community-engaged approach, we would develop a multilevel culturally acceptable intervention to address the inequitable burden of HPV-related diseases among Black individuals by increasing vaccination and promoting cervical cancer screening.

Funding

This work was supported by Division of Cancer Prevention, National Cancer Institute: [grant number 3P30CA177558-08S1] University of Kentucky Markey Cancer Center - Cancer Center Support Grant. Geographical Management of Cancer Health Disparities (GMaP) Supplement. The content is solely the responsibility of the authors and does not necessarily represent the official views of the sponsors.

Appendix

Key informants semi-structured interview guide:

  • In your experience, do you think Black adults are knowledgeable enough about HPV? Why is that?

  • What types of concerns or beliefs have you heard about the HPV vaccine?

  • In your experience, what barriers prevent Blacks from following recommendations for HPV vaccination? (Think of barriers pertaining to individuals, within the community, health care setting, policy level)

  • What can be done to encourage Black adults to follow recommendation for HPV vaccination? The following sets of questions are about cervical cancer screening among Black women.

  • In your experience, what barriers prevent Black women from following recommendations for cervical cancer screening? (Think of barriers pertaining to individuals, within the community, health care setting, policy level)

  • Is there any other information that might help us understand cervical cancer beliefs and attitudes among Blacks?

  • What suggestions might help us develop a program to improve HPV knowledge, vaccination and cervical cancer screening for Black adults?

Footnotes

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethical statement

The Institutional Review Board at the University of Kentucky, Lexington, Kentucky [protocol number 55357], approved the study. Participants provided consent prior to study commencement.

References

  1. Allaire BT, Ekweme D, Hoerger TJ, DeGroff A, Rim SH, Subramanian S, and Miller JW. 2019. “Cost-effectiveness of Patient Navigation for Breast Cancer Screening in the National Breast and Cervical Cancer Early Detection Program.” Cancer Causes & Control 30 (9): 923–929. doi: 10.1007/s10552-019-01200-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Amuta-Jimenez AO, Smith GPA, and Brown KK. 2022. “Patterns and Correlates of Cervical Cancer Prevention among Black Immigrant and African American Women in the USA: The Role of Ethnicity and Culture.” Journal of Cancer Education 37 (3): 798–805. doi: 10.1007/s13187-020-01884-1. [DOI] [PubMed] [Google Scholar]
  3. Boersma P, and Black LI. 2020. “Human Papillomavirus Vaccination among Adults Aged 18–26, 2013–2018. National Center for Health Statistics (U.S.).” Division of Health Interview Statistics, Data Brief (354): 1–8. [PubMed] [Google Scholar]
  4. Centers for Disease Control and Prevention. The National Immunization Surveys (NIS), 2008–2020. https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/pubs-presentations/NIS-teen-vac-coverage-estimates-2015-2021.htm.
  5. Centers for Disease Control and Prevention. 2022. Cancers Associated with Human Papillomavirus, United States—2015–2019. USCS Data Brief, no. 32. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022. https://www.cdc.gov/cancer/uscs/about/data-briefs/no31-hpv-assoc-cancers-UnitedStates-2015-2019.htm. [Google Scholar]
  6. Centers for Disease Control and Prevention, Division of Cancer Prevention and Control. 2020. “Screening test.” https://www.cdc.gov/cancer/dcpc/prevention/screening.htm.
  7. Colón-López V, Medina-Laabes DT, Abreu RS, Díaz Miranda OL, Ortiz AP, Fernández ME, and Hull PC. 2021. “Understanding Parents’ Views Toward the Newly Enacted HPV Vaccine School Entry Policy in Puerto Rico: A Qualitative Study.” BMC Public Health 21 (1): 1–9. doi: 10.1186/s12889-021-11952-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Creswell JW, and Poth CN. 2016. Qualitative Inquiry & Research Design: Choosing among Five Approaches. Los Angeles, CA: Sage Publications. [Google Scholar]
  9. Cunningham-Erves J, Forbes L, Ivankova N, Mayo-Gamble T, Kelly-Taylor K, and Deakings J. 2018. “Black Mother’s Intention to Vaccinate Daughters Against HPV: A Mixed Methods Approach to Identify Opportunities for Targeted Communication.” Gynecologic Oncology 149 (3): 506–512. doi: 10.1016/j.ygyno.2018.03.047. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Czeisler MÉ, Marynak K, Clarke KEN, Salah Z, Shakya I, Thierry JM, Ali N, et al. 2020. “Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns – United States, June 2020.” MMWR. Morbidity and Mortality Weekly Report 69 (36): 1250–1257. doi: 10.15585/mmwr.mm6936a4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. DeSantis CE, Siegel RL, Sauer AG, Miller KD, Fedewa SA, Alcaraz KI, and Jemal A. 2016. “Cancer Statistics for African Americans, 2016: Progress and Opportunities in Reducing Racial Disparities.” CA: A Cancer Journal for Clinicians 66 (4): 290–308. doi: 10.3322/caac.21340. [DOI] [PubMed] [Google Scholar]
  12. DiClemente RJ, Murray CC, Graham T, and Still J. 2015. “Overcoming Barriers to HPV Vaccination: A Randomized Clinical Trial of a Culturally-Tailored, Media Intervention among African American Girls.” Human Vaccines & Immunotherapeutics 11 (12): 2883–2894. doi: 10.1080/21645515.2015.1070996. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Dubé E, Vivion M, and MacDonald NE. 2015. “Vaccine Hesitancy, Vaccine Refusal and the Anti-Vaccine Movement: Influence, Impact and Implications.” Expert Review of Vaccines 14 (1): 99–117. doi: 10.1586/14760584.2015.964212. [DOI] [PubMed] [Google Scholar]
  14. Elder JP, Lytle L, Sallis JF, Young DR, Steckler A, Simons-Morton D, Stone E, et al. 2007. “A Description of the Social-Ecological Framework Used in the Trial of Activity for Adolescent Girls (TAAG).” Health Education Research 22 (2): 155–165. doi: 10.1093/her/cyl059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Fowler CI, Saraiya M, Moskosky SB, Miller JW, Gable J, and Mautone-Smith N. 2017. “Trends in Cervical Cancer Screening in Title X-Funded Health Centers — United States, 2005–2015.” MMWR. Morbidity and Mortality Weekly Report 66 (37): 981–985. doi: 10.15585/mmwr.mm6637a4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Galbraith-Gyan KV, Lechuga J, Jenerette CM, Palmer MH, Moore AD, and Hamilton JB. 2019. “African-American Parents’ and Daughters’ Beliefs About HPV Infection and the HPV Vaccine.” Public Health Nursing 36 (2): 134–143. doi: 10.1111/phn.12565. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Gerend MA, Shepherd MA, Lustria ML, and Shepherd JE. 2016. “Predictors of Provider Recommendation for HPV Vaccine among Young Adult Men and Women: Findings from a Cross-Sectional Survey.” Sexually Transmitted Infections 92 (2): 104–107. doi: 10.1136/sextrans-2015-052088. [DOI] [PubMed] [Google Scholar]
  18. Gonzalez P, Castaneda SF, Mills PJ, Talavera GA, Elder JP, and Gallo LC. 2012. “Determinants of Breast, Cervical and Colorectal Cancer Screening Adherence in Mexican-American Women.” Journal of Community Health 37 (2): 421–433. doi: 10.1007/s10900-011-9459-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Greyson D, Vriesema-Magnuson C, and Bettinger JA. 2019. “Impact of School Vaccination Mandates on Pediatric Vaccination Coverage: A Systematic Review.” CMAJ Open 7 (3): E524. doi: 10.9778/cmajo.20180191. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Henderson RL, Zoucha R, Colbert A, and Braxter BJ. 2022. “Exploring Cultural Factors of Human Papillomavirus Vaccination Acceptance in African Americans: An Integrative Review.” Journal of Transcultural Nursing 33 (6): 723–731. doi: 10.1177/10436596221125899. [DOI] [PubMed] [Google Scholar]
  21. Ince-Cushman D, Correa JA, Shuldiner J, and Segouin J. 2013. “Association of Primary Care Physician Sex with Cervical Cancer and Mammography Screening.” Canadian Family Physician Medecin de Famille Canadien 59 (1): e11–e18. [PMC free article] [PubMed] [Google Scholar]
  22. Kayser K, Washington A, Anderson G, Harris LM, Lee HY, and LaJoie AS. 2022. “Perceived Barriers and Facilitators in Accessing Cervical Cancer Screening: The Voices of Women in a Low-Income Urban Community.” Family & Community Health 45 (1): 46–57. doi: 10.1097/fch.0000000000000312. [DOI] [PubMed] [Google Scholar]
  23. Lafata JE, Cooper G, Divine G, Oja-Tebbe N, and Flocke SA. 2014. “Patient–Physician Colorectal Cancer Screening Discussion Content and Patients’ Use of Colorectal Cancer Screening.” Patient Education and Counseling 94 (1): 76–82. doi: 10.1016/j.pec.2013.09.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lin SC, McKinley D, Sripipatana A, and Makaroff L. 2017. “Colorectal Cancer Screening at US Community Health Centers: Examination of Sociodemographic Disparities and Association with Patient-Provider Communication.” Cancer 123 (21): 4185–4192. doi: 10.1002/cncr.30855. [DOI] [PubMed] [Google Scholar]
  25. Lincoln CE, and Mamiya LH. 1990. The Black Church in the African American Experience. Duke University Press. [Google Scholar]
  26. Maness SB, Reitzel LR, Watkins KL, and McNeill LH. 2016. “HPV Awareness, Knowledge and Vaccination Attitudes among Church-Going African-American Women.” American Journal of Health Behavior 40 (6): 771–778. doi: 10.5993/ajhb.40.6.9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Maxwell AE, Lucas-Wright A, Santifer RE, Vargas C, Gatson J, and Chang LC. 2019. “Promoting Cancer Screening in Partnership with Health Ministries in 9 African American Churches in South Los Angeles: An Implementation Pilot Study.” Preventing Chronic Disease 16: E128. doi: 10.5888/pcd16.190135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. McLeroy KR, Bibeau D, Steckler A, and Glanz K. 1988. “An Ecological Perspective on Health Promotion Programs.” Health Education Quarterly 15 (4): 351–377. doi: 10.1177/109019818801500401. [DOI] [PubMed] [Google Scholar]
  29. McQuillan G, Kruszon-Moran D, Markowitz LE, Unger ER, and Paulose-Ram R. 2017. Prevalence of HPV in Adults Aged 18–69: United States, 2011–2014. NCHS Data Brief, no 280. Hyattsville, MD: National Center for Health Statistics. [Google Scholar]
  30. Miller S 2009. “Cultural Humility is the First Step to Becoming Global Care Providers.” Journal of Obstetric, Gynecologic & Neonatal Nursing 38 (1): 92–93. doi: 10.1111/j.1552-6909.2008.00311.x. [DOI] [PubMed] [Google Scholar]
  31. National Conference of State Legislatures. 2021. HPV Vaccine: State Legislation and Regulation https://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx. [Google Scholar]
  32. Nolan J, Renderos TB, Hynson J, Dai X, Chow W, Christie A, and Mangione TW. 2014. “Barriers to Cervical Cancer Screening and Follow-up Care among Black Women in Massachusetts.” Journal of Obstetric, Gynecologic & Neonatal Nursing 43 (5): 580–588. doi: 10.1111/1552-6909.12488. [DOI] [PubMed] [Google Scholar]
  33. Osazuwa-Peters N, Simpson MC, Rohde RL, Challapalli SD, Massa ST, and Adjei Boakye E. 2021. “Differences in Sociodemographic Correlates of Human Papillomavirus-Associated Cancer Survival in the United States.” Cancer Control 28: 107327482110418. doi: 10.1177/10732748211041894. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Patton MQ 2014. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. SAGE. [Google Scholar]
  35. Rogers CR, Mitchell JA, Franta GJ, Foster MJ, and Shires D. 2017. “Masculinity, Racism, Social Support, and Colorectal Cancer Screening Uptake among African American Men: A Systematic Review.” American Journal of Men’s Health 11 (5): 1486–1500. doi: 10.1177/1557988315611227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Sage SK, Hawkins-Taylor C, Crockett RA Sr, and Balls-Berry JE. 2020. ““Girl, Just Pray … ”: Factors That Influence Breast and Cervical Cancer Screening among Black Women in Rochester, MN.” Journal of the National Medical Association 112 (5): 454–467. doi: 10.1016/j.jnma.2019.02.006. [DOI] [PubMed] [Google Scholar]
  37. Shi R, Devarakonda S, Liu L, Taylor H, and Mills G. 2014. “Factors Associated with Genital Human Papillomavirus Infection among Adult Females in the United States, NHANES 2007–2010.” BMC Research Notes 7 (1): 1–8. doi: 10.1186/1756-0500-7-544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Smalls BL, Aroh A, McQuerry K, Adegboyega A, Schoenberg N, and Hatcher J. 2018. “Social Support and Breast Cancer Screening in Rural Appalachia.” Psycho-Oncology 27 (9): 2281–2288. doi: 10.1002/pon.4828. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Speziale HS, Streubert HJ, and Carpenter DR. 2011. “Qualitative Research in NursingAdvancing the Humanistic Imperative.” Wolters Kluwer Lippincott Williams & Wilkins. [Google Scholar]
  40. Steinwachs D, Allen JD, Barlow WE, Duncan RP, Egede LE, Friedman LS, Keating NL, Kim P, Lave JR, and LaVeist TA. 2010. “National Institutes of Health State-of-the-Science Conference Statement: Enhancing Use and Quality of Colorectal Cancer Screening.” Annals of Internal Medicine 152 (10): 663–667. doi: 10.7326/0003-4819-152-10-201005180-00237. [DOI] [PubMed] [Google Scholar]
  41. Underhill ML, and Kiviniemi MT. 2012. “The Association of Perceived Provider–Patient Communication and Relationship Quality with Colorectal Cancer Screening.” Health Education & Behavior 39 (5): 555–563. doi: 10.1177/1090198111421800. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. U.S. Cancer Statistics Working Group. 2022. U.S. Cancer Statistics Data Visualizations Tool, based on 2021 submission data (1999–2019): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; www.cdc.gov/cancer/dataviz, June 2022. [Google Scholar]
  43. U.S. Census Bureau Quick Facts: Kentucky. 2021. https://www.census.gov/quickfacts/KY.
  44. Ylitalo KR, Lee H, and Mehta NK. 2013. “Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/Ethnicity in the US National Immunization Survey.” American Journal of Public Health 103 (1): 164–169. doi: 10.2105/ajph.2011.300600. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES