Misconceptions and knowledge gaps about HPV, cervical cancer, and HPV vaccination among Central American immigrant parents in the United States

ABSTRACT

Cervical cancer is one of the most preventable cancers globally, yet it remains a significant health issue, primarily due to persistent high-risk human papillomavirus (HPV) infection. Ethnic minority and immigrant populations experience notable gaps in knowledge about HPV, the HPV vaccine, and its link to cervical cancer. This study assessed awareness and understanding of HPV, the HPV vaccine, and its connection to cervical cancer among Central American immigrant parents in the United States. A qualitative, exploratory study used in-depth, semi-structured interviews. Both inductive and deductive thematic analyses were conducted with MAXQDA software to identify key themes related to participants’ awareness of HPV, the vaccine, and its link to cervical cancer. Fifty-six parents (33 mothers, 23 fathers; mean age = 42.7 years), nearly all foreign-born (92.8%) from El Salvador, Guatemala, and Honduras (average 17.3 years of U.S. residency), participated in the study. Only 26.8% (n = 15) demonstrated clear awareness of cervical cancer. Overall knowledge was limited, particularly regarding diagnosis and the role of HPV in cancer development. Furthermore, understanding of the HPV vaccine’s role in prevention was minimal, with many unaware of its ability to reduce the risk of HPV-related cancers, including cervical cancer. Findings reveal significant knowledge gaps and misconceptions about HPV, cervical cancer, and the HPV vaccine, highlighting the need for targeted educational interventions to improve understanding and increase vaccination rates in immigrant and ethnic minority communities. Efforts should focus on improving understanding of cervical cancer detection, HPV’s role in cancer development, and the vaccine’s effectiveness in prevention.

Introduction

Cervical cancer is one of the most preventable cancers globally, yet it remains a significant health challenge, with most cases linked to persistent infection with high-risk human papillomavirus (HPV).^1,2 HPV, a sexually transmitted infection (STI), is responsible for nearly all cervical cancer cases and is also associated with other anogenital and oropharyngeal cancers. In response to this challenge, the World Health Organization (WHO) launched a strategy in 2020 to eliminate cervical cancer by 2030.^3,4 This ambitious initiative aims to reduce both incidence and mortality through increased HPV vaccination, enhanced screening, and improved access to treatment.^3,4 However, achieving this goal is hindered by various factors, including structural and societal barriers, particularly within under-resourced and immigrant communities, where significant knowledge gaps about HPV and cervical cancer persist.^3–6 In this context, the WHO’s campaign underscores the critical need for targeted vaccination efforts to reduce the global burden of cervical cancer, which remains a leading cause of cancer-related mortality among women worldwide.^3,4 Such efforts are especially crucial for populations facing significant barriers to healthcare access, including immigrant communities, who often experience lower vaccination rates and limited access to preventive care.

Minoritized ethnic and immigrant populations in the United States (U.S.) face significant disparities in HPV-related health outcomes.^5–8 Despite the availability of preventive methods, such as the HPV vaccine, many remain unaware of the link between HPV and cervical cancer or the vaccine’s crucial role in prevention.^7,8 This lack of awareness is compounded by socio-cultural and systemic barriers, including low health literacy, limited or inadequate access to healthcare, and cultural misconceptions about HPV and vaccines.^5–10

Cultural beliefs influence attitudes toward HPV and cervical cancer.^9,10 In many cultures, cancer may be attributed to divine will, lifestyle choices, or environmental factors rather than HPV infection.^9,10 Additionally, cultural views on reproductive health can affect how the HPV vaccine is perceived, especially when discussions around sexual health and vaccination are considered taboo.^9,10 These cultural factors hinder vaccine acceptance and information-seeking behaviors, limiting the adoption of preventive measures like vaccination.^9,10

Health literacy plays a crucial role in navigating healthcare. However, for many minoritized populations, it is further hindered by language barriers and limited access to healthcare services.^11,12 Many individuals lack education about HPV, often because they consider information on the topic culturally irrelevant or because of the absence of relevant health education programs.^11,12 As a result, misconceptions about the HPV vaccine, such as fears of side effects or safety concerns, persist despite scientific evidence supporting its efficacy.^11,12 Additionally, traditional health practices and cultural beliefs – such as the perception that certain health issues, like cervical cancer, are “taboo” or too personal to discuss – may contribute to resistance to preventive measures like the HPV vaccine.^11–13 In some cultures, there may also be a belief that vaccines are unnecessary or harmful based on previous experiences with healthcare systems or distrust in medical institutions.^11,12

Misinformation, particularly through social media and personal networks, further complicates these issues.^14,15 False claims about vaccines – such as concerns about infertility or government control – undermine trust in healthcare systems, discouraging individuals from seeking vaccines or screenings.^14,15 Combined with inadequate outreach and negative healthcare experiences, this environment increases the likelihood of low HPV vaccination rates, exacerbating health disparities and leaving vulnerable populations at higher risk for persistent HPV infections and cervical cancer.^9,16,17

Primary prevention through HPV vaccination is one of the most effective strategies for reducing cervical cancer rates.^4,18,19 Recent studies have demonstrated the significant effectiveness of the HPV vaccine in reducing the incidence of cervical cancer. In particular, data from populations with high vaccination coverage have shown a remarkable decline in cervical cancer cases, with some regions reporting zero cases.²⁰ This provides compelling evidence of the vaccine’s ability to prevent HPV-related cervical carcinogenesis, underscoring its critical public health value. Vaccines such as Gardasil and Cervarix have been proven to prevent infection with high-risk HPV strains responsible for the majority of cervical cancers. However, vaccine uptake remains low in certain populations, highlighting the need for targeted interventions to address the social, cultural, and educational barriers faced by Central American immigrants.^21,22 Research underscores the importance of culturally tailored health education programs designed to overcome misconceptions and improve understanding of the vaccine. Such initiatives are critical in enhancing vaccine acceptability and promoting more proactive preventive health behaviors within these communities.^21–24

Additionally, secondary prevention through regular cervical cancer screenings (e.g., Pap smears or HPV tests) is essential for detecting precancerous lesions early.^25,26 However, these services are often underused in underserved communities due to geographic, financial, and cultural barriers, including a lack of awareness about the importance of screenings.²⁶ Even individuals who seek care may not receive comprehensive preventive services, particularly if healthcare providers fail to emphasize the need for screenings or follow-ups, especially when language and cultural barriers are present.¹⁴

While immigrant communities in the U.S. face various barriers to HPV vaccination and cervical cancer prevention, Latina women encounter additional, unique challenges that further exacerbate the health disparities they face.^5,6 Cervical cancer is a significant public health concern for Latina women in the United States, as they are disproportionately affected by higher rates of cervical cancer incidence and mortality compared to other ethnic groups.⁵ Factors such as limited access to healthcare, language barriers, and cultural differences contribute to lower screening rates and delayed diagnoses among Latina women.^5,6,27–29 Furthermore, socio-economic challenges, such as lower income and lack of health insurance, further increase the vulnerability of this population.^{3,5,6,27–29} Early detection through regular Pap smears and HPV vaccination is crucial for preventing cervical cancer, yet many Latina women face barriers to these services.^3,5,6 Addressing these disparities through targeted outreach, culturally sensitive education, and improved healthcare access is essential to reduce the burden of cervical cancer on Latina communities.⁶

Existing literature on HPV prevention within Latino populations in the U.S. offers valuable insights, but there are significant gaps in understanding the health behaviors, knowledge, and vaccination uptake of Central American immigrants, particularly those from the Northern Triangle countries – El Salvador, Guatemala, and Honduras.^27–29 While research has focused on broader Latino populations, the unique challenges faced by Central American immigrants are often overlooked in health initiatives.^21–24 This lack of targeted research creates a gap in our understanding of how cultural, linguistic, and socio-economic factors influence HPV prevention within this subgroup.^27,28 Moreover, much of the existing research has not addressed how misinformation, language barriers, and limited healthcare access intersect to affect HPV vaccine acceptance among this specific group.

This study aims to fill these gaps by assessing HPV awareness and understanding of the HPV vaccine among Central American immigrant parents in the U.S., particularly in relation to its connection to cervical cancer. By exploring the unique challenges faced by this population, the research will provide critical insights into knowledge gaps, attitudes, and barriers to vaccination, thereby informing strategies to improve HPV vaccination uptake and promote health equity in underrepresented communities.³⁰

Materials and methods

Study design

This exploratory, descriptive qualitative study aimed to explore the awareness, beliefs, and practices related to HPV and cervical cancer prevention among Central American immigrant parents of children aged 11–17 years in the U.S. Given the limited existing literature on HPV knowledge within this population, qualitative methods were chosen to gain a deeper understanding of the cultural, social, and contextual factors influencing health behaviors.³¹ Qualitative research allows for the collection of rich, detailed narratives that provide valuable insights into parents’ awareness and knowledge of HPV, the HPV vaccine, and its role in preventing HPV-associated cancers, including cervical cancer.¹⁹

Sample and participant recruitment

Participants in this study were Central American immigrant parents residing in the U.S., specifically from the Northern Triangle countries (El Salvador, Guatemala, and Honduras), with children aged 11–17. They were purposively selected to capture a diverse range of experiences and perspectives, building on strategies used in our previous studies with Latino immigrants, including Central Americans.^32–34

Inclusion criteria were: (1) self-identification as Central American; (2) age 21 or older; (3) at least one child aged 11–17; (4) fluency in Spanish and/or English; (5) willingness to provide informed consent for audio recording; and (6) residence in the U.S. for at least six months, to capture experiences with the U.S. healthcare system. The target sample size was 40–50 parents, with equal representation of mothers and fathers, to ensure data saturation.

Participants were recruited through community organizations, healthcare clinics, churches, social media, and events serving Central American immigrants. Recruitment strategies, including direct outreach by research staff and network sampling (where enrolled participants referred others), had been effective in prior studies.^32–34 Staff members, embedded in the Central American community, used personal networks to facilitate recruitment, ensuring a diverse sample with varying levels of HPV vaccine knowledge.

The recruitment area for the study included U.S. states with significant Central American immigrant populations, such as California, Florida, Texas, New York, New Jersey, Illinois, Maryland, Virginia, Arizona, and Massachusetts.³⁵ The recruitment strategy was specifically tailored to urban areas with dense immigrant communities. While there were no geographic restrictions, the majority of participants who responded to the study were from Massachusetts, where the study was primarily conducted. As a qualitative study, the target sample size was relatively small, with an initial goal of recruiting approximately 40–48 parents. Most of the participants who enrolled were recruited from urban areas, particularly the Greater Boston area, which has a large Central American immigrant population.

Data collection

Data were collected through in-depth interviews conducted via Zoom, allowing for face-to-face interaction while ensuring participant safety and convenience. At the beginning of each interview, participants were informed about the study’s purpose, procedures, and their rights, including the right to withdraw at any time without penalty. Informed consent was obtained electronically before the interview began.

After consent, participants completed a brief interviewer-administered questionnaire to gather sociodemographic information, including age, marital status, education, household income, number of children, and primary language spoken at home. The questionnaire was adapted from previous studies with Latino and Central American immigrants.^32,33 Acculturation was measured using the Short Acculturation Scale for Hispanics (SASH), a validated 12-item tool that assesses language use, media preferences, and ethnic social relations, with good reliability (Cronbach’s alpha: 0.92–0.89 overall; 0.89 for language, 0.88 for media, and 0.72 for social relations).^36,37 An acculturation score was calculated by averaging the 12 items on a scale from 1 to 5. Scores of 2.99 or above indicate higher levels of acculturation, while scores below 2.99 indicate lower levels.³⁶

Following the brief survey, the in-depth qualitative interview was conducted using a semi-structured interview guide developed from the literature to explore parents’ knowledge and beliefs about HPV, cervical cancer, the HPV vaccine, and barriers to vaccination.^{8,23,24,27–29} Topics included awareness of HPV and its link to cervical cancer, perceived benefits and risks of the vaccine, cultural factors influencing vaccine decisions, and trust in healthcare providers. The interviews were designed to be open-ended, allowing for detailed narratives about participants’ experiences and views. Probing questions were used throughout to encourage deeper reflection and to explore the reasoning behind participants’ responses, ensuring a comprehensive understanding of their perspectives. The interview guide was pre-tested and adjusted for clarity and relevance. Each interview lasted approximately 45–60 minutes and was audio-recorded with participant consent.

Data analysis

The audio-recorded interviews were transcribed verbatim in Spanish, the participants’ primary language, and anonymized to ensure confidentiality. The transcripts were then analyzed using thematic analysis, which allowed for the identification of both explicit and implicit meanings, providing a nuanced understanding of the factors influencing HPV vaccination decisions.^38,39 A codebook was developed based on existing literature and emerging themes from the data. Data analysis employed both inductive and deductive approaches. The inductive approach allowed for the generation of new insights directly from the data, while the deductive approach was informed by the available literature on prior studies conducted with immigrant and Latino populations, enabling the application of existing concepts to interpret the findings. This combination of approaches provided a comprehensive understanding by capturing both emergent and preexisting themes. MAXQDA software was used to facilitate systematic coding and organization of the data.^39,40

Two bilingual researchers independently coded the transcripts, resolving discrepancies through discussion to ensure consensus and accuracy. The analysis was conducted iteratively, with regular team discussions to refine codes and identify patterns in the data. Key themes included beliefs about HPV and cervical cancer, knowledge of the link between HPV and cervical cancer, and understanding the role of the HPV vaccine in preventing cervical cancer.

To ensure rigor and validity, the research team engaged in debriefing sessions and reflected on potential biases throughout the analysis process.³⁰ Reflexivity was maintained by keeping detailed field notes and holding regular team discussions to minimize biases.^29,30

Ethical considerations

This study was approved by the Institutional Review Board (IRB) at the University of Massachusetts Boston (protocol code #30362022047, approval date March 10, 2022) for studies involving human participants. All participants were assured of the confidentiality and anonymity of their responses, with personal identifiers removed from the transcripts. Audio recordings were securely stored and accessible only to the research team. Participants were compensated with an incentive of $40.00 for their time and in recognition of their contribution to the study.

Given the vulnerable nature of the population, special care was taken to ensure the research was conducted with cultural sensitivity and respect for participants’ backgrounds and experiences. Due to the mixed migratory status of the participants, additional precautions were taken to ensure they felt safe throughout the process. This included anonymizing identifying information, securely storing data accessible only to the research team, and reassuring participants that they could withdraw from the study at any time without facing any consequences. These measures were crucial to fostering a trusting environment for participants, given the sensitive nature of their backgrounds.

Results

Fifty-six parents (33 mothers and 23 fathers) participated in the study. The average age was 42.7 years. Most parents (71.4%) were married or living with a partner. Approximately 36% had completed high school, and 66% were employed full-time. About 30.4% reported a household annual income between $15,000 and $50,000.

The majority of parents (92.8%) were born outside the U.S., originating from the following Central American countries – El Salvador (32.1%), Guatemala (32.1%), and Honduras (28.6%). Foreign-born parents had lived in the U.S. for an average of 17.3 years, with 42.9% residing in the U.S. for 20 or more years. Nearly 84% spoke Spanish at home. Most parents lived in Massachusetts (66.1%), with the remainder in other states. About 58.9% identified as Catholic. In terms of healthcare, 57.1% had public insurance, while 16.1% were uninsured. Additional details on the sample are provided in Table 1.

Table 1.

Sociodemographic and cultural characteristics of the sample (N = 56).

Variables	Total (N = 56)			Mothers (n = 33)			Fathers (n = 23)
	Mean (SD)	N	%	Mean (SD)	N	%	Mean (SD)	N	%	p-value
Age (range 27–58 years)	42.7 (7.4)	56	100	41.6 (7.1)	33	100	44.2 (8.2)	23	100	0.21
25–35 years		15	26.8		10	30.3		5	21.7	0.48
36–45 years		22	39.3		12	36.4		10	43.5
46–55 years		16	28.6		10	30.3		6	26.1
≥56 years		3	5.3		1	3.0		2	8.7
Marital status
Married/Living with Partner		40	71.4		24	72.7		16	69.6	0.80
Divorced/Separated/Widow		10	17.8		5	15.2		5	21.7
Single		6	10.8		4	12.1		2	8.7
Educational attainment
Less than high school		21	27.4		10	30.3		11	47.8	0.18
High School		20	35.8		12	36.4		8	34.8
More than high school		15	26.8		11	33.3		4	17.4
Employment status
Employed full-time (≥30 hours/week)		37	66.1		18	54.6		19	82.7	0.03
Employed part-time (<30 hours week)		7	12.5		4	12.1		3	13.0
Unemployed		12	21.4		11	33.3		1	4.3
Household annual income
≤ $15,000 – < $50,000		17	30.4		12	36.3		5	21.7	0.24
≥ $50,000 – < $85,000		18	32.1		11	33.3		7	23.4
≥ $85,000		16	28.6		5	15.2		11	47.8
Don’t know/Declined to report		5	8.9		5	15.2		0	0
Parent country of birth
El Salvador		18	32.1		11	33.3		7	23.4	0.82
Guatemala		18	32.1		10	30.3		8	34.8
Honduras		16	28.6		10	30.3		6	26.1
United States		4	7.2		2	6.1		2	8.7
Parent years of residency in the U.S.1	17.3 10.2)	56	100	16.3 (9.1)	33	100	18.1 (10.9)	23	100	0.51
<10 years		8	14.3		7	22.6		1	4.8	0.08
≥10 years – < 20 years		20	35.8		12	38.7		8	38.1
≥20 years		24	42.9		12	38.7		12	57.1
State of Residence
Massachusetts		37	66.1		24	72.7		13	56.7	0.21
Maryland		4	7.1		1	3.0		3	13.0
Virginia		6	10.8		3	9.1		3	13.0
New York		4	7.1		2	6.1		2	8.7
North Carolina		2	3.5		2	6.1		0	0
Illinois		1	1.8		1	3.0		0	0
New Jersey		1	1.8		0	0		1	4.3
California		1	1.8		0	0		1	4.3
Primary language spoken at home
Spanish		47	83.8		30	90.9		17	73.9	0.09
English		3	5.4		1	3.0		2	8.7
Both Spanish and English		6	10.8		2	6.1		4	17.4
Parent SASH score2
<2.99		56	100		33	100		23	100	–
Parent Religious affiliation
Catholic		33	58.9		18	54.6		15	65.2	0.43
Protestant		15	26.8		11	33.3		4	17.4
None		8	14.3		4	12.1		4	17.4
Parent healthcare insurance status
Public/government-sponsored		32	57.1		20	60.6		12	52.2	0.53
Private		15	26.8		7	21.2		8	34.8
Uninsured		9	16.1		6	18.2		3	13.0
Number of children between 11–17 years
1		39	69.6		23	69.7		16	69.6	0.99
2		11	19.6		4	12.1		7	23.4
3		6	10.8		6	18.2		0	0
Gender of children
Male		44	57.1		26	55.3		18	60.0	0.68
Female		33	42.9		21	44.7		12	40.0
Age of children
11–12 years		21	27.3		12	25.5		9	30.0	0.67
13–15 years		29	37.7		17	36.2		12	40.0
16–17 years		27	35.0		18	38.3		9	30.0
Children country of birth
El Salvador		10	13.0		8	17.0		2	6.6	0.36
Guatemala		8	10.4		5	10.6		3	10.0
Honduras		10	13.0		6	12.8		4	13.4
United States		49	63.6		28	59.6		21	70.0
Child healthcare insurance status
Insured		77	100		47	100		30	100	–
HCP recommended HPV vaccine
Yes		26	33.8		16	34.0		10	33.3	0.94
No		51	66.2		31	66.0		20	66.7
Child received at least one dose of vaccine
Yes		26	33.8		16	34.0		10	23.3	0.94
No		51	66.2		31	66.0		20	76.7
Child received at least one dose vaccine
Male (n = 44)		12	27.3		8	30.8		4	22.2	0.63
Female (n = 33)		14	42.4		8	38.1		6	50

¹Only parents born outside the United States were included in the study.

²The Short Acculturation Scale for Hispanics (SASH) was administered to all parents included in the study.

Awareness of cervical cancer

Among the 56 participants in this study, only 15 (26.8%) demonstrated clear awareness of cervical cancer. Many participants had limited or no direct knowledge of the condition, often relying on community sources, personal experiences, and mass media for information. Several participants were familiar with cervical cancer through family members or acquaintances who had been diagnosed. For example, one participant shared, “My mom had cancer, she got cervical cancer. But they detected it early, and they operated, and thank God, it’s been about 15 years, and she hasn’t had any recurrence or anything like that” (Salvadoran mother, 58 years old).

Others referred to cancer more generally, recognizing it as a common health issue but not specifically identifying cervical cancer. One participant mentioned, “When you hear the word cancer, the first thing you think of is breast cancer, cervical cancer, which are the ones that are more common” (Honduran mother, 59 years old). Fathers, in particular, demonstrated more limited awareness. For example, one father said, “I’ve heard of throat cancer, but cancer of the … how do you call it? The cervix? No, I don’t really know much about it.” (Salvadoran father, 44 years old).

Knowledge of cervical cancer

While some participants were aware that HPV is linked to cervical cancer, they lacked detailed knowledge of how the virus causes the disease or how to prevent it. One mother said, “I think they told me about it once, and I’ve also heard, like, short commercials, but not very often, um, that it can cause a certain type of cancer. I’m not sure if it’s in the cervix.” (Salvadoran mother, 39 years old). Another said, “Honestly, I haven’t, I haven’t informed myself about the procedures.” (Honduran mother, 42 years old).

Regarding detection, most participants were unsure about how cervical cancer is diagnosed. Some believed that gynecological exams, Pap smears, or ultrasounds could detect the disease, but others were uncertain about the diagnostic process. One mother said, “Well, with cancer, I know they sometimes do ultrasounds or what they call Pap smears.” (Honduran mother, 42 years old). Another admitted, “I… I don’t know, honestly, how it’s detected.” (Salvadoran mother, 39 years old), highlighting the lack of clarity regarding cervical cancer detection methods.

Beliefs about cervical cancer and HPV

In addition to their knowledge about cervical cancer and HPV, participants expressed various beliefs about the causes and risk factors of cervical cancer. Many believed that women are more susceptible to HPV, although their understanding of the virus was often vague or incomplete, reflecting a general perception of heightened vulnerability without a clear understanding of HPV’s role. Some participants also linked HPV to increased risks for cervical cancer, though these connections were not always well-articulated. For example, one participant stated, “I think more women [are affected]… Because I believe that our body is more… sensitive to certain things, and our body, as women, reacts faster” (Salvadoran mother, 45 years old).

One mother mentioned, “I think they told me about it once, and I’ve also heard, like, short commercials, but not very often, um, that it can cause a certain type of cancer. I’m not sure if it’s in the cervix.” (Salvadoran mother, 39 years old). One father shared, “I think, if I’m correct, it’s something to do with cervical cancer.” (Salvadoran father, 47 years old).

Many believed that women are more susceptible to HPV, although their understanding of the virus was often vague or incomplete. This reflected a general perception of heightened vulnerability without a clear understanding of HPV’s role. For instance, one participant stated, “I think women more than men. Because I think, um, our body is more… sensitive to certain things, and our body as women reacts faster.” (Salvadoran mother, 37 years old).

One father said, “Well, I think it’s more common in women, but I think, if women have it, it’s possible, and if it’s transferred, men can have it, because if they have an active sex life.” (Honduran father, 50 years old). Another mentioned, “I think it is more the woman, I imagine, right? Or it could be the same, but I think it is more for women.” (Guatemalan father, 34 years old).

Participants’ knowledge and beliefs about HPV and Its link to cervical cancer

When asked about the relationship between HPV and cervical cancer, many participants lacked clear knowledge about the connection between the two. Only a few participants were able to accurately identify HPV as a known cause of cervical cancer. For example, one participant made the direct connection between HPV and cervical cancer, stating, “It’s transmitted through sexual activity” (Guatemalan mother, 39 years old), though they did not elaborate on the specific role of HPV in their diagnosis. However, this accurate knowledge was rare among participants.

Additionally, some participants expressed uncertainty or confusion about the link between HPV and cervical cancer. Some had heard of HPV’s potential connection to cancer but were unsure about the details. One participant said, “I think they told me about that once, and I’ve also heard commercials about it, but not very often, that it can cause a certain type of cancer, I’m not sure if it’s in the cervix” (Salvadoran mother, 39 years old). Another mentioned, “Eh, um, it’s not necessarily just cervical cancer, but it affects more areas. But I’m not really informed about it…” (Guatemalan mother, 41 years old).

Furthermore, some participants expressed uncertainty about HPV’s role in cancer. For example, one participant correctly identified that HPV could cause throat cancer but was unsure of the specifics, stating, “I’ve heard of throat cancer, cancer of the … how do you call it? The cervix? No, I don’t really know much about it” (Salvadoran father, 44 years old). Another participant, however, had a misconception, saying, “I think it’s something that affects the fallopian tubes… that’s where the cancer is” (Guatemalan mother, 39 years old).

Understanding of the HPV vaccine and its role in cervical cancer prevention

Participants demonstrated varying levels of understanding regarding the role of the HPV vaccine in preventing cervical cancer. Some were aware that the vaccine could prevent the disease. One participant stated, “If we don’t get the HPV vaccine, we’re at greater risk of having cervical cancer” (Salvadoran mother, 42 years old). Another mentioned, “For young people, I imagine that this vaccine helps to prevent it” (Honduran mother, 55 years old).

Some participants believed the vaccine might reduce the severity of cervical cancer. For example, one shared, “Well, what little I’ve understood is that it’s for prevention. If I were to get it, it wouldn’t be as severe as if I didn’t have the vaccine” (Salvadoran mother, 37 years old). Another added, “The purpose is so that … let’s say … if I get it, maybe the disease wouldn’t be as severe, and it would be good for them to get it because it could help prevent the disease from becoming more complicated or help them heal faster” (Guatemalan mother, 36 years old). One father also said, “It could be to help people or avoid pain” (Guatemalan father, 35 years old).

In addition to the HPV vaccine, some participants believed that cervical cancer could be prevented through regular medical checkups or the use of condoms. One participant commented, “But if one were consistent with consultations, with regular medical checkups, I think it could be prevented” (Guatemalan mother, 39 years old). Another added, “I think that [sighs]… if we talk about it being caused by having a relationship with someone infected, then everyone should use a condom” (Salvadoran mother, 39 years old). However, a few participants were uncertain about specific preventive measures. One participant admitted, “Honestly, I haven’t looked into the information” (Honduran mother, 42 years old), indicating a general lack of awareness about prevention beyond basic health practices.

Attitudes and behaviors related to the HPV vaccine

The results revealed that participants generally held positive attitudes toward the HPV vaccine, with most expressing a willingness to vaccinate their children. For example, one mother mentioned, “Yes, yes, I agree” (Salvadoran mother, 47 years old), and one father said, “If it helps prevent cancer, then of course, I agree” (Salvadoran father, 44 years old). Among those with some knowledge of cervical cancer and the HPV vaccine, all indicated they would vaccinate their children. For instance, one participant said, “I’m going to talk to the pediatrician and ask them to please vaccinate all three of them” (Salvadoran mother, 58 years old), while another stated, “Yes, I would vaccinate them because… uh, I think all human beings are vulnerable to these kinds of diseases, especially deadly ones” (Guatemalan father, 45 years old).

While many participants expressed no preference for vaccinating sons or daughters differently, some emphasized the importance of vaccinating girls, citing the association with cervical cancer. One mother said, “Well, it would be the same… because for women, it helps prevent [cervical cancer]” (Honduran mother, 59 years old). Another mentioned, “I think it’s the same for both, but as I said at the beginning, we’ve always been taught that women are more exposed, we’re more at risk” (Salvadoran mother, 35 years old).

Among participants who lacked knowledge of the HPV vaccine, some expressed the need for more information before deciding to vaccinate their children. One participant explained, “Well, first, I would investigate to see how effective it is, and if… well, if they can get it” (Guatemalan mother, 39 years old). Another said, “Well, I don’t know because I don’t have much information. Maybe I’d have to look into other cases of people who got the HPV vaccine and see how it worked for them” (Honduran mother, 30 years old).

In contrast, a few parents, particularly those without detailed knowledge of the vaccine, voiced concerns about potential side effects, such as the possibility of infertility. One participant shared their hesitation, saying, “They opposed vaccinating girls aged 11 to 17 with this vaccine because it was supposedly for preventing HPV, but there was also the possibility that these girls could become sterile. And I think that was the fear I had, which is why I didn’t want my daughter to get that vaccine” (Honduran mother, 42 years old). Another father commented, “Well, it could have… side effects. Damage to organs, well, because vaccines are chemicals, and our organs might not be capable of handling chemicals that could be too strong” (Salvadoran father, 39 years old). Another thought, “First, I would research to see if anyone else has taken it, what effects they experienced, if they had any problems…” (Guatemalan father, 39 years old).

Discussion

This study aimed to assess the awareness and understanding of the link between HPV and cervical cancer, as well as the role of the HPV vaccine in prevention, among Central American immigrant parents residing in the U.S. The findings reveal significant gaps in knowledge about cervical cancer, HPV, and the HPV vaccine within this population, highlighting barriers to awareness and knowledge that may hinder efforts to reduce cervical cancer rates.

Low awareness and knowledge gaps about cervical cancer

While many participants recognized cancer as a significant health concern, cervical cancer was not universally acknowledged or understood. Only 26.8% demonstrated clear awareness of the disease, and many were familiar with it through personal experiences, such as family members diagnosed with cervical cancer. This suggests a gap in public health messaging, as cervical cancer was less recognized and mentioned by participants compared to other cancers, like breast or uterine cancer, which were more frequently quoted. Previous research has also highlighted that awareness of cervical cancer is often lower, possibly due to the stigma surrounding reproductive health and the relative rarity of cervical cancer compared to more widely discussed cancers like breast cancer.^7,41,42

Participants’ knowledge of cervical cancer detection methods was similarly limited. While some correctly identified gynecological exams and Pap smears as part of the diagnostic process, others expressed uncertainty about how the disease is detected. This lack of clarity about detection may be related to the absence of information and guidance from health professionals about secondary prevention strategies for cervical cancer (Pap smears) and even unawareness of the importance of this test. This finding is consistent with research suggesting that limited awareness of cervical cancer screening is a barrier to early detection.^42–46 Educational interventions that emphasize the importance of regular screening and early detection are essential, particularly in populations with low knowledge.⁴⁷

Misconceptions and understanding of cervical cancer and HPV

Participants expressed varying beliefs about the causes of cervical cancer, with some linking it to HPV. However, their understanding of the virus was often unclear or incomplete.^{43–46,48,49} While some recognized HPV as a risk factor for cervical cancer, others confused it with other types of cancer or did not fully grasp its role in cancer development.^39,40 This suggests a need for more targeted education to clarify the link between HPV and cervical cancer.⁴⁷

Misconceptions about HPV’s role were also prevalent, indicating a general lack of accurate information about the virus and its risks.^45–49 These knowledge gaps could have undermined the effectiveness of HPV vaccination campaigns, which rely on the public’s understanding of HPV as a preventable cause of cervical cancer.^50–52 The misconceptions about HPV also highlighted broader issues in public health communication regarding sexually transmitted infections and cancer prevention.^44–46 Despite HPV infection being the primary risk factor for cervical cancer, many participants did not fully understand its long-term consequences or the preventive measures available, such as vaccination. Educating the public about HPV’s specific role in cervical cancer and its prevention through vaccination is crucial for reducing stigma and improving health literacy.^50–52

Understanding the HPV vaccine and its role in cervical cancer prevention

Participants’ understanding of the HPV vaccine and its role in preventing cervical cancer varied. While some were aware that the vaccine could prevent cervical cancer, others believed it could only reduce the severity of the disease. This suggests a partial understanding of the vaccine’s potential, highlighting the need for clearer explanations about how it works to prevent infection with high-risk HPV types, thereby reducing the risk of cervical cancer. These findings align with previous research indicating that knowledge of the HPV vaccine and its benefits remains limited, particularly in communities with low health literacy.^9,48,53–60

Some participants also believed the vaccine offered broader benefits, such as preventing other cancers or reducing the severity of cervical cancer. However, there were gaps in understanding its specific role in preventing cervical cancer. This underscores the need for clear, accessible communication about the vaccine’s effectiveness, particularly in underserved populations where misinformation is more prevalent.^55–63 These gaps in understanding among study participants highlight the importance of targeted messaging on the HPV vaccine’s role in cervical cancer prevention, especially in communities with limited access to reliable information.^21,22

Misinformation about the HPV vaccine and infertility concerns

Several participants expressed concerns about the potential side effects of the HPV vaccine, particularly the possibility of infertility. Misinformation about this potential side effect was often spread through social media and other informal sources, leading to hesitations about vaccinating children. This concern highlights the significant role that misinformation plays in vaccine hesitancy and underscores the importance of addressing these fears with clear, reliable, and accessible information.

Additionally, some participants indicated that they would need more information before deciding about vaccinating their children. This reflects the uncertainty caused by a lack of trusted sources and the prevalence of misinformation in certain communities. The results show that misinformation about the vaccine’s potential risks – such as infertility – was a key barrier to vaccine acceptance.^14,15 This underscores the need for targeted communication efforts to counteract these misconceptions, particularly in underserved populations where social media and word-of-mouth may be primary sources of health information.^21,22 Clear, accessible communication about the HPV vaccine’s safety and its proven benefits is essential for increasing vaccination rates and preventing the spread of misinformation.^30,64,65

Provider recommendation and patient navigation as key predictors

While education is critical in raising awareness, the role of healthcare providers in vaccine acceptance cannot be overstated. Provider recommendation has consistently been shown to be one of the strongest predictors of HPV vaccine uptake.^22,66,67,68 Healthcare providers, particularly those working with immigrant and underserved populations, must be equipped with the tools and support to confidently recommend the HPV vaccine. This includes integrating HPV vaccination discussions into routine care, such as through checklists in electronic health records (EHRs) or policy changes that incentivize providers to initiate these conversations.

Additionally, public health efforts should not only focus on broad education campaigns but also implement patient navigation strategies to assist parents in understanding the vaccine, answering their questions, and addressing concerns.⁶⁵ Patient navigation can help ensure that parents have the support needed to make informed decisions, particularly when there are cultural or language barriers.⁶⁹ Public health campaigns should provide clear, accessible, and accurate information to both healthcare providers and parents, emphasizing the vaccine’s safety, benefits, and availability.^70,71

Regional adaptation of education campaigns

While education through mass media is important, public health campaigns must also be tailored to the specific needs of different regions.^69,70 Not all participants lived in Massachusetts, and regional differences in access to healthcare, cultural context, and local health policies may affect how public health messaging is received. Therefore, efforts to educate the public about the HPV vaccine should be adaptable to local needs and conditions, ensuring that materials and strategies are culturally appropriate and resonate with diverse communities.

Limitations and strengths

Findings of this study should be considered in light of some limitations. Selection bias may have affected results, as purposive and snowball sampling could have overrepresented more engaged individuals with stronger opinions, limiting the diversity of views.⁷² Another limitation is the reliance on self-reported data, which may introduce biases, as participants could overestimate their knowledge.⁷³ Additionally, the context-specific nature of the study means findings may not be easily generalizable to other immigrant groups due to varying cultural, socio-economic, and healthcare factors.⁷² A key limitation is that we did not ask participants about their cervical cancer screening practices during the qualitative interviews. As a result, we lack data on whether participants have regular Pap smears or understand the purpose of these screenings, which could have influenced their knowledge of cervical cancer risk and the need for the HPV vaccine.

Despite these limitations, the study’s strengths lie in its use of semi-structured interviews, which provided rich, in-depth insights into participants’ perspectives on HPV, the HPV vaccine, and cervical cancer.^30,31 Although the sample size is small, this is typical for qualitative research, which prioritizes depth of insight over generalizability. The purposive and snowball sampling strategies enabled the inclusion of a diverse group of participants.^31,72 This study contributes valuable, culturally relevant data that can inform interventions aimed at improving awareness and knowledge of HPV, the HPV vaccine, and cervical cancer.

Implications for public health education for Central American immigrants

The findings of this study highlight several key implications for public health education initiatives aimed at increasing awareness and understanding of cervical cancer, HPV, and the HPV vaccine within Central American immigrant communities in the U.S. The gaps in knowledge and prevalence of misconceptions underscore the need for targeted, culturally sensitive interventions that address both informational and emotional barriers to HPV vaccination and cervical cancer prevention, specifically for this population.

• Educational Campaigns and Misconceptions: Many participants were unaware of the link between HPV and cervical cancer and confused it with other cancers. Public health campaigns should provide clear, culturally relevant information about HPV and its preventability through vaccination. These campaigns should address misconceptions and partner with local leaders and organizations to reach immigrant communities effectively.

• Promoting the HPV Vaccine: A significant gap in knowledge about the HPV vaccine’s role in preventing cervical cancer exists. Public health efforts should focus on educating Central American immigrants, using Spanish and other relevant languages, about the vaccine’s effectiveness. Highlighting long-term benefits, such as reducing future health burdens, may resonate with this population.

• Improving Access to Information: To influence attitudes toward HPV vaccination, public health efforts should prioritize distributing multilingual (primarily Spanish) materials through trusted local sources like community centers, schools, and churches. Healthcare providers familiar with the cultural nuances of Central American immigrants should also be trained to explain the vaccine’s importance clearly.

• Enhancing Screening Access: Given limited awareness of cervical cancer detection, public health initiatives should focus on increasing access to Pap smears and HPV testing, particularly in low-resource settings. Programs should offer low-cost screenings, transportation assistance, and educational materials to reach immigrant women facing cultural, economic, or language barriers.

• Addressing Social Media Misinformation: Public health education must tackle misinformation on social media about the HPV vaccine, particularly fears about infertility. Targeting these sources with accurate, evidence-based information through trusted platforms and community leaders can help counteract these misconceptions.

• Provider Recommendations and Patient Navigation: Healthcare providers should be trained to confidently recommend the HPV vaccine and address concerns about its safety. Patient navigation services can assist immigrant families by providing support with scheduling, language barriers, and vaccine-related questions.

• Adapting Campaigns to Local Contexts: Public health campaigns should be tailored to regional differences in healthcare access and cultural context. Ensuring materials and strategies are culturally and regionally appropriate will improve the effectiveness of these initiatives.

• Empowering Community Leaders: Community leaders, including faith-based figures and local organizations, should be equipped to advocate for HPV vaccination and cervical cancer prevention. These leaders can act as trusted messengers, bridging the gap between public health officials and immigrant communities.

Conclusions

This study revealed significant gaps in knowledge and pervasive misconceptions about cervical cancer, HPV, and the HPV vaccine. To address these issues, public health initiatives must prioritize comprehensive, culturally sensitive education that increases awareness, clarifies misunderstandings, and highlights the role of the HPV vaccine in preventing HPV-related cancers, including cervical cancer. Efforts should focus on improving understanding of cervical cancer detection, explaining the role HPV infection in cancer development, and promoting the vaccine’s effectiveness in cancer prevention.

Targeted educational campaigns are essential to dispel myths and provide clear, evidence-based information about the role of the HPV vaccine in preventing cancer. Public health programs should not only educate the public but also actively engage healthcare providers in recommending the HPV vaccine. Given that provider recommendation is a strong predictor of vaccine acceptance, public health initiatives must equip healthcare providers with the tools and support they need to confidently discuss the vaccine with patients. This can include policy changes, such as checklists in electronic health records (EHRs) that prompt providers to discuss the vaccine as they would any other adolescent vaccine and ensuring that reimbursement structures support these discussions.

Moreover, while mass education efforts are critical, these programs should be complemented by patient navigation strategies in health services to support parents in understanding and making informed decisions about the vaccine. Ensuring access to multilingual, culturally tailored resources will further reduce barriers to vaccine uptake, particularly in underserved regions.

Public health campaigns must also consider regional differences in knowledge and concerns, adapting the messaging and delivery based on local needs and contexts.

In line with the WHO call to eliminate cervical cancer by 2030, public health campaigns must deliver culturally tailored, accessible, and accurate information to increase understanding of the HPV vaccine and its critical role in cancer prevention. By including provider recommendations and supporting patient navigation in health services, these campaigns can foster greater awareness, reduce misconceptions, and ultimately increase vaccination rates, helping to achieve this global health goal.

Biography

Ana Cristina Lindsay, DrPH, DDS, MPH, is a community-based public health researcher with specialized training in pediatric dentistry and maternal and child health. Her research focuses on advancing health equity by understanding and addressing health disparities affecting Latin American populations both in the United States and Latin America. Dr. Lindsay’s scholarship emphasizes prevention and health promotion, particularly in the areas of obesity and cancer, through improving lifestyle behaviors and addressing early life determinants of health. Her research program specifically targets the prevention of obesity during the critical early life stages of pregnancy and early childhood, with the goal of reducing the long-term risk of chronic diseases. Additionally, Dr. Lindsay works to increase the uptake of the HPV vaccine as a means of preventing HPV-associated cancers, employing mixed methods approaches to develop culturally tailored interventions and public health strategies. Her work is informed by her commitment to community-based participatory research, aiming to empower and engage underserved populations in creating sustainable health solutions.

Funding Statement

This work was supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme LLC (Ana Cristina Lindsay, Principal Investigator). The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC. Merck Sharp & Dohme LLC.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contributions

ACL and DLN contributed substantially to the conception of the work. ACL, VAM, DD, DL, AHN, and NRC participated on the acquisition of data for the work; ACL, DLN, and VAM participated on the analysis interpretation; ACL, DLN and VAM participated in the drafting of the work. ACL, DLN and VAM reviewed it critically for important intellectual content. ACL acquired the funding for the research. All authors approved the final version to be published and agree to be responsible for all aspects of the work to ensure that issues related to the accuracy or completeness of any part of the work are adequately investigated and resolved.

Compliance with ethical standards

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the University of Massachusetts Boston (protocol code #30362022047, approval date March 10, 2022) for studies involving humans.

Data availability statement

Due to privacy and ethical restrictions, the data that support the findings of this analysis are not publicly available; however, they are available upon request from the corresponding author.