Parental acceptance and uptake of the HPV vaccine among African-Americans and Latinos in the United States: A literature review

Abstract

Background:

African-Americans and Latinos suffer the highest cervical cancer burden compared to other populations and have sub-optimal HPV vaccination rates.

Objective:

To condense research findings of studies conducted with African-Americans and Latinos on factors associated with HPV vaccine acceptability and uptake.

Methods:

Standards for conducting an integrative review were used. PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases were searched.

Results:

Awareness about HPV and the HPV vaccine varied by demographics of parents. For Latino parents, acculturation and awareness were associated. However, findings were mixed regarding the association between acculturation and knowledge. Among African-Americans, higher socioeconomic status (SES) and awareness were associated. Sexuality-related concerns, concerns about safety and low perceived risk of daughter’s acquiring HPV emerged as barriers to vaccination among Latinos and African-Americans. Among Latinos, vaccine acceptability was associated with the vaccine’s cancer prevention benefits and a provider’s recommendation. Among African-Americans, acceptability was associated with awareness, perceived risk of acquiring HPV, religion, and a provider’s recommendation. Few interventions have been developed to increase HPV vaccine acceptance. Importantly, few studies assessed the influence of culture on vaccine acceptance and uptake.

Conclusions:

Future research should be informed by culture-centered theories as this is the first step to inform the development of culturally-grounded interventions.

1. Introduction

Approximately 12,900 new cervical cancer cases occur in the U.S. and 4100 result in death yearly (American Cancer Society (ACS), 2015). African-American women and Latinas have the highest cervical cancer incidence rates (9.2 and 9.9 new cases per 100,000 persons, respectively) compared to non-Hispanic white women (7.7 new cases per 100,000 persons). African-American women and Latinas also have a higher cervical cancer mortality rate (4.0 and 2.7 deaths per 100,000 persons, respectively) compared to non-Hispanic white women (2.1 deaths per 100,000 persons) (National Cancer Institute, 2015).

Since 1975, African-American women have had the highest cervical cancer mortality rate compared to non-Hispanic white women (ACS, 2013; Tabatabai et al., 2014) and one contributing factor is delayed diagnosis. Although the overall five-year survival rate of cervical cancer is 91% when diagnosed at an early stage, only 39% of African-American women are diagnosed early compared to 48% of non-Hispanic white women (ACS, 2015). Latinas have the second highest cervical cancer mortality rate and are 64% more likely to be diagnosed with cervical cancer than non-Hispanic white women (ACS, 2012; Ennis et al., 2011). Similar to African-Americans, Latinas are also more likely to be diagnosed with cervical cancer at later stages (ACS, 2012).

Cervical cancer is caused by persistent infection with the Human Papillomavirus (HPV), which is the most common sexually transmitted infection (STI) in the U.S. (Centers for Disease Control and Prevention (CDC), 2014; Walboomers et al., 1999). HPV is linked to cervical, vulvar, vaginal, anal, penile, and oropharyngeal cancers, afflicting women and men of varied races and ethnicities. For example, more white women get vulvar cancer than women of other races or ethnicities, and more African-Americans and non-Hispanic whites get oropharyngeal cancer than Asian Pacific Islanders and American Indian/Alaska Natives (CDC, 2012). A greater proportion of African-American women and Latinas are diagnosed with vaginal cancers than non-Hispanic white women. Similarly, African-American men and Latinos have higher incidence rates of anal and penile cancers, respectively, than men of other races (CDC, 2012).

In 2006, a quadrivalent vaccine that protects against four types of HPV (6, 11, 16, 18), responsible for approximately 70% of cervical cancer cases and 90% of genital warts cases, was licensed in the U.S. In 2014, a 9-valent vaccine offering protection from other HPV types (31, 33, 45, 52, and 58) was licensed (Joura et al., 2014), increasing cervical cancer protection from 70% to 90% (Serrano et al., 2012). The Advisory Committee on Immunization Practices (ACIP) recommends the vaccine for males and females ages 11–12 and catch-up vaccination for males ages 13–21 and females ages 13–26 (CDC, 2015a). The HPV vaccines are administered in a three-dose series at 0 month, 1–2 months and 6 months and research indicates that the vaccines are safe and effective (Garland et al., 2015; Joura et al., 2015; Markowitz et al., 2013; Stokley et al., 2014).

HPV vaccination coverage for females, ages 13–17 years, has increased significantly between 2013 and 2014. Coverage for 1 and 3 doses increased from 56.7% to 36.8% in 2013 to 60% and 39.7% in 2014 (CDC, 2015b). Latinas and African-Americans have higher initiation rates (66.3% and 66.4%, respectively) than non-Hispanic whites (56.1%). Completion rates are highest for Latinas (72.8%), followed by non-Hispanic whites (70.6%), and African-Americans (61.6%) (CDC, 2015b). These vaccination rates are promising considering that rates remained unchanged between 2011 and 2012 (CDC, 2013). Nevertheless, rates are still below the rates of other childhood recommended vaccinations and below the Healthy People 2020 vaccination goal of 80% (CDC, 2015b; HealthyPeople.gov, 2015).

The purpose of this systematic literature review is to condense findings of studies conducted with African-Americans and Latinos to understand factors associated with HPV vaccine acceptability and uptake among parents of adolescent females. This study focuses on parents of adolescent females due to the increased availability of studies targeting females as ACIP recommendations for routine vaccination for males occurred years later (CDC, 2011). A review of the literature on parental HPV vaccine acceptance among African-American and Latinos is timely as it is imperative to provide direction to future research and practice in hopes of ameliorating disparities in cervical cancer incidence and mortality.

2. Methods

Standards for conducting an integrative review were used (Cooper, 2009; Whittemore and Knafl, 2005). PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO databases were searched. Inclusion criteria were studies that: (1) focused on African-Americans and/or Latinos in the U.S., (2) examined attitudes, awareness, barriers, acceptability, knowledge, and perceptions related to HPV infection or the HPV vaccine, (3) were published in peer reviewed journals, and (4) consisted of samples composed of parents or caregivers of adolescent girls 9–17 years old. Exclusion criteria were reports that consisted of duplicates, editorials, commentaries, dissertations, conference abstracts or literature reviews studies and studies that consisted of: (1) college women only, or adolescent girls without parents only, (2) male adolescents only, or male adults only, (3) healthcare providers only. Studies were limited to African-American and Latino parents because they experience a greater burden of certain HPV-related cancers and due to below optimal HPV vaccine completion rates in comparison to non-Hispanic whites. Studies were limited to female parents as research indicates they are the key decision makers for HPV vaccination (McRee et al., 2010). Studies were also limited to U.S. populations since the availability and policies governing the HPV vaccine differ from other parts of the world. For instance, compared to the U.S., other industrialized countries now mandate the HPV vaccine.

The same search terms were used in all three databases. The HPV vaccine has only been licensed in the U.S. for the past 10 years and therefore the search was not time restricted. Studies were searched through January 2015. The primary search term used was: “((hpv[Text Word] OR papillomavirus[Text Word]) AND vaccin* [Text Word]) AND (African American*[Text Word] OR Hispanic* [Text Word] OR Latina*[Text Word] OR Latino*[Text Word] OR Mexican*[Text Word]) AND (parent*[tw] OR mother*[tw] OR father*[tw] OR grandparent*[tw] OR grandmother*[tw] OR grandfather*[tw]).” After the initial search was conducted, the following search terms were separately added to the primary search term: AND attitude*; aware*; AND knowl*; AND barrier*; AND perception*. We excluded Medline records from our CINAHL search. The matrix method, an organizational tool, was used to extract study characteristics (design, theoretical framework, independent variables, dependent variables, etc.) to allow comparison on specific variables and sample characteristics (race/ethnicity, age, urban and rural, etc.) (Garrard, 2010; Whittemore and Knafl, 2005).

3. Results

Fig. 1 presents the study screening process. Initially, 421 studies were retrieved from all three databases: 299 studies from PubMed, 27 studies from CINAHL (excluding Medline records) and 95 studies from PsycINFO. All studies were transferred to Endnote and Excel. Three hundred and ten duplicates and 44 other studies were eliminated according to specific exclusion criteria. A total of 354 studies were eliminated leaving 67 studies in this systematic literature review.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. U.S. = United States; HCP = Health Care Provider; HPV = Human papillomavirus. Description of screening process and results.

Table 1 presents the characteristics of studies reviewed. The majority of studies used a quantitative cross-sectional design of telephone, web-based or in person surveys (n = 36). The other most frequent studies were of secondary analyses of state and national surveys (n = 12). Eleven studies used a qualitative approach, four studies used both qualitative and quantitative methods, one study used a longitudinal cohort design, and five tested interventions. Only 12 studies collected data from a rural setting. The sample sizes ranged from 17 mothers to 148,350 mother-daughter dyads (Kaiser Permanente California electronic medical record). Only 15 studies were conducted with Blacks or African-Americans and sample composition ranged from 59% to 100%, of which, only eight used exclusively Black or African-American samples.

Table 1.

Characteristics of Studies Included in Review

Study	Study design	Theoretical framework	Sample description
Allen, Othus et al. (2010)	Quantitative cross-sectional survey between September 2007- January 2009	Integrative model of behavioral prediction	N = 476 Parents of adolescent girls aged 9–17yo. NHW: 48%; Black: 30%; Hispanic: 22%
Allen, de Jesus et al. (2012)	Qualitative focus groups and interviews	NTS	N = 64 Parents of adolescent girls aged 9–17yo. Black: 59%; NHW: 23%; Hispanic: 19%
Bair, Mays et al. (2008)	Qualitative semi-structured interviews from November 2004 to March 2005	NTS	N = 40 Latina mothers
Baldwin, Bruce et al. (2013)	Quantitative cross-sectional survey between December 2008- May 2010	Heuristic systematic model & elaboration likelihood model	N = 256 Mothers of unvaccinated daughters aged 8–22yo. Black: 48.8%; Hispanic: 29.3%; NHW: 18%; Other: 3.9%
Barnack-Tavlaris, Garcini et al. (2014)	Quantitative analysis of 2007 California Health Interview Survey	NTS	N = 2,994 Mothers of daughters aged 8yo or older. U.S. born mothers: NHW: 84.7%; Hispanic: 12.4%; Asian: 2.9% Foreign-born mothers: NHW: 14.4%; Hispanic: 54%; Asian: 31.5%
Blackman, Thurman et al. (2013)	Quantitative cross-sectional survey between 2008 and 2010	NTS	N = 555 Black participants from the U.S. and Bahamas.
Brawner, Baker et al. (2012)	Qualitative and Quantitative	TPB	N = 48 Parents 100% African American
Casillas, Singhal et al. (2011)	Quantitative cross-sectional survey between January 2009- November 2009	NTS	N = 294 Minority women Latina: 55%; Chinese: 22%; Korean: 9%; African American: 9%
Cates, Brewer et al. (2009)	Quantitative cross-sectional survey between April and May 2006	NTS	N = 138 Women Black: n = 91; White: n = 47
Cates, Shafer et al. (2010)	Quantitative analysis of 2008 Child Health Assessment and Monitoring Program survey	NTS	N = 696 Parents of females aged 10–17yo. Racial demographic of daughters: NHW: 63.3%; African American: 22.9% (race not reported for parents)
Chao, Slezak et al. (2009)	Quantitative analysis of Kaiser Permanente Southern California health records	NTS	N = 148,350 Mother-daughter pairs NHW: n = 27,052 (18.2%); African American: n = 10,855 (7.3%); Hispanic: n = 38,125 (25.7%); Asian: n = 5,739 (3.8%); Other: n = 66,579 (44.9%)
Constantine and Jerman (2007)	Quantitative and Qualitative	NTS	N = 522 Parents Hispanic: n = 200 (38.2%); NHW: n = 211 (40.5%); African American: n = 36 (6.9%); Asian: n = 40 (7.7%); Other: n = 28 (5.4%)
Cox, Cox, et al. (2010)	3×2 Between subjects factorial design	NTS	N = 471 Mothers of girls aged 11–16yo. NHW: 58.4%; African American: 21.4%; Hispanic: 19.7%
Davlin, Berenson et al. (2015)	Quantitative questionnaire between September 2011 and September 2012	NTS	N = 638 Mothers of children aged 9–18yo.
Dorell, Yankey et al. (2011)	Quantitative analysis of 2008–2009 National Immunization Survey-Teen	NTS	N = 18,228 Adolescent girls aged 13–17yo. NHW: n = 12,810; Hispanic: n = 2,125; Black: n = 1,951
Dorell, Yankey et al. (2014)	Quantitative analysis of 2010 National Immunization Survey-Teen	NTS	N = 4,103 Adolescent girls aged 13–17yo. NHW: n = 2,794; Black: n = 473; Hispanic: n = 509; Other: n = 327
Fazekas, Brewer et al. (2008)	Quantitative survey between April 2006-May 2006	HBM	N = 146 Rural women African American: n = 91 (62%); White: n = 47 (32%); American Indian: n = 3 (2%); Not stated: n = 5 (3%)
Fishman, Taylor et al. (2014)	Quantitative longitudinal study	NTS	N = 149 Parents (mothers and fathers) African American: n = 40 (95.2%); Hispanic: n = 4 (2.7%) N = 211 daughters aged 13–18yo.
Gerend, Zapata et al. (2013)	Quantitative cross-sectional survey	NTS	N = 200 Latina mothers
Getrich, Broidy et al. (2014)	Quantitative and Qualitative between September 2009 and March 2009	NTS	N = 30 Interviews n = 8 clinicians; n = 10 mothers; n = 12 girls aged 12–17yo
Gilkey, Magnus et al. (2014)	Quantitative analysis of 2010 National Immunization Survey-Teen	HBM	N = 9,623 Parents Children demographics: NHW: 66%; Black: 16%; Hispanic: 11%
Guerry, De Rosa et al. (2011)	Quantitative cross-sectional survey between October 2007 and June 2008	NTS	N = 509 Parents Hispanic: 81%; African American: 16%
Hamlish, Clarke et al. (2012)	Qualitative	NTS	N = 19 African American mother-daughter dyads.
Hughes, Jones et al. (2011)	Qualitative semi-structured individual interviews between March 2010 and June 2010	NTS	N = 20 Triads (mother-daughter-clinician) Mothers: Black: n = 12, White: n = 8
Hughes, Cates et al. (2009)	Quantitative cross-sectional survey between July 2007-October 2007	NTS	N = 889 Caregivers of adolescent girls aged 10–18yo. White: 70%; African American: 23%
Hull, Williams et al. (2014)	Qualitative focus groups and interviews	Dissemination of innovation theory; Community-based participatory marketing model	n = 34 African American adolescent females aged 11–18yo; n = 31 mothers
Joseph et al. (2012)	Quantitative cross-sectional survey between October 2008 and March 2009	HBM	n = 19 African Americans; n = 51 Haitians
Kepka, Coronado et al. (2011)	Quantitative experimental study between July –September 2009	NTS	N = 88 Hispanic parents of daughters aged 9–17yo. n = 78 mothers; n = 10 fathers
Kepka, Ding et al. (2015)	Quantitative cross-sectional between August 2013- October 2013	NTS	N = 118 Latino parents of adolescent boys and girls aged 11–17yo.
Kepka, Warner et al. (2014)	Quantitative cross-sectional survey between August 2013-October 2013	Social ecological framework	N = 67 Latino parents of children 11–17yo.
Kepka, Coronado et al. (2012)	Qualitative study between June 2008- January 2009	Grounded theory used for data analysis	N = 36 Latino parents of daughters aged 9–14yo. n = 25 mothers; n = 11 fathers
Kepka, Ulrich et al. (2012)	Quantitative cross-sectional survey between July 2009-September 2009	Social ecological framework	N = 78 Rural Hispanic mothers of daughters aged 9–17yo.
Kester, Zimet et al. (2013)	Quantitative cross-sectional survey conducted in 2010	NTS	N = 501 Mother-daughter pairs White: 59%; Hispanic: 22%; Black: 14%; Other: 5%
Lau, Lin et al. (2012)	Quantitative cross-sectional analysis of 2007 National Survey of Children’s Health	NTS	N = 16,139 Adolescent females aged 12–17yo. HPV vaccine series non-initiators’ race/ethnicity: White: 59%; Latino: 18%; African American: 17%; Asian/Pacific Islander: 3% HPV vaccine series initiators’ race/ethnicity: White: 61%; Latino: 16%; African American: 15%; Asian/Pacific Islander: 3%
Laz, Rahman et al. (2012)	Quantitative analysis of the 2010 National Health Interview Survey	NTS	N = 2,171 National sample of adolescent girls aged 11–17yo. NHW: n = 940; Black: n = 384; Asian: n = 127; Hispanic: n = 645; Other: n = 75
Lechuga, Swain et al. (2011)	Quantitative experimental study	Prospect theory	N = 150 Mothers Hispanic: n = 50; NHW: n = 50; African American: n = 50
Lechuga, Vera-Cala et al. (2014)	Quantitative cross-sectional phone survey	HBM, TPB	N = 296 Latinas
Litton, Desmond et al. (2011)	Quantitative cross-sectional statewide telephone survey between December 2008- April 2009	NTS	N = 421 female caregivers of adolescent girls aged 10–14yo. NHW: 89.8%; African American: 9%
Luque, Raychowdhury et al. (2012)	Qualitative focus groups and interviews	Social marketing framework	N = 20 Hispanic immigrants and HCPs n = 5 mothers; n = 7 fathers; n = 8 HCPs
Morales-Campos, Markham et al. (2013)	Qualitative focus groups	Grounded theory used for data analysis	n = 24 Hispanic mothers; n = 28 Hispanic girls
McRee, Reiter et al. (2010)	Quantitative cross-sectional telephone survey between July- October 2007	NTS	N = 1,220 Parents of adolescent girls aged 10–18yo. NHW: 74%; Black: 20.3%; Hispanic: 5.7%
Middleman and Tung (2010)	Quantitative cross-sectional questionnaire in May 2009.	NTS	N = 615 Caregivers of girls aged 11–14yo. Hispanic: 81%; Black: 16%
Perkins, Pierre-Joseph et al. (2010)	Qualitative interview between June 2007 and February 2008	Grounded theory used for data analysis	N = 73 Parents NHW: n = 19 (26%); African American: n = 18 (25%); Afro-Caribbean or African: n = 15 (21%); Latino: n = 21 (29%)
Podolsky, Cremer et al. (2009)	Quantitative cross-sectional survey	NTS	N = 148 Latina mothers from New York City; N = 160 Parents from El Salvador
Polonijo, Carpiano et al. (2013)	Quantitative analyses of 2008, 2009, and 2010 United States National Immunization Survey-Teen	Fundamental cause theory	N = 41,358 Mothers of adolescent girls aged 13–17yo. NHW: 60.7%; Hispanic: 17.6%, Black: 14.8%; Other: 6.9%
Ramirez, Jessop et al. (2014)	Qualitative ethnographic study	NTS	N = 17 Hispanic mothers and grandmothers
Rand, Schaffer et al. (2011)	Quantitative cross-sectional telephone survey between March 2007 and April 2008	HBM	n = 430 Parents of adolescents; n = 208 adolescents NHW: 51%; Black: 31%; Hispanic: 13%
Read, Joseph et al. (2010)	Quantitative cross-sectional survey between January 2007- June 2008	NTS	n = 175 Adolescent girls aged 13–19yo; n = 74 Parents African American: 50.6%; African-Caribbean: 39.3%; Hispanic: 10.1%
Reimer, Houlihan et al. (2013)	Quantitative cross-sectional survey between June 2009- December 2009	TRA, TPB	N = 309 White and Latina women.
Reiter, Cates et al. (2010)	Quantitative analysis of 2008 Child Health Assessment and Monitoring survey	NTS	N = 617 Parents of adolescent females. Daughters: NHW: 67.6%; Black: 20.3%; Hispanic: 6.7%; Other race: 12%
Robitz, Gottlieb et al. (2011)	Quantitative cross-sectional survey between October 2007-June 2008	NTS	N = 484 Parents of adolescents girls Hispanic: 81%; African American: 15%
Sadigh, Dempsey et al. (2012)	Quantitative analysis of the 2006– 2008 National Survey of Family Growth	NTS	N = 4,283 Mothers of girls aged 9–18yo. African American: 15%; Hispanic: 17%
Sanderson, Coker et al. (2009)	Quantitative cross-sectional survey between April 2007- April 2008	NTS	n = 190 HPV positive Latina women; n = 215 HPV negative Latina women
Sanders Thompson, Arnold et al. (2012)	Qualitative cross-sectional questionnaire between February 2009- June 2009	NTS	N = 30 African Americans n = 25 women; n = 5 men
Savas, Fernandez et al. (2012)	Quantitative cross-sectional survey between September 2009- October 2009	NTS	N = 99 Parents of daughters aged 9–17yo. Hispanic: 47%; Black: 43%; NHW: 3.4%; Other: 7%
Shelton, Snavely et al. (2013)	Quantitative cross-sectional survey between September 2007- January 2008	TPB	N = 476 Parents of daughters aged 9–17yo. White: 47%; Black: 30%; Hispanic: 23%
Stevens, Caughy et al. (2013)	Quantitative cross-sectional survey between December 2008- May 2010	NTS	N = 288 Hispanic mothers of females aged 8–22yo.
Thomas, Strickland et al. (2012)	Quantitative cross-sectional survey	HBM	N = 400 African American parents of girls aged 9–13yo.
Thomas, Strickland et al. (2013)	Quantitative cross-sectional survey between September 2009- April 2011	HBM	N = 519 Parents African American: 77.3%
Thompson, Arnold et al. (2011)	Quantitative cross-sectional survey between February 2009- June 2009	NTS	N = 200 African American parents of females aged 9–17yo.
Tsui, Singhal et al. (2013)	Quantitative cross-sectional survey between January 2009- November 2009	NTS	N = 468 Parents of adolescent girls aged 9–18yo. Latina: 51.6%; Chinese: 19.3%; Korean: 14.2%; African American: 8.1%; Other: 6.8%
Venkatesh, Acosta et al. (2013)	Quantitative cross-sectional survey during the 2011– 2012 school year	NTS	N = 219 Parents of middle-school children. NHW: 82.8%; Hispanic: 17.2%; Black: 8.9%; Asian: 7.9%
Warner, Lai et al. (2014)	Quantitative and Qualitative study between August 2013- October 2013	Social ecological framework	N = 52 Latino parents of children aged 11–17yo.
Watts, Joseph et al. (2009)	Quantitative cross-sectional survey between August 2007-April 2008	NTS	n = 86 Latinas aged 18–55yo; n =141 non-Latinas aged 18–55yo
Wisk, Allchin et al. (2014)	Quantitative cross-sectional analysis of 2010 National Health Interview Survey	NTS	N = 5,735 Parents of pre-adolescents and adolescents aged 8–17yo. White: 61.2%; Black: 14.3%; Hispanic: 19.3%
Wu, Porch et al. (2010)	Quantitative cross-sectional survey between July 2007- April 2008	NTS	N = 206 Latina women
Yeganeh, Curtis et al. (2010)	Quantitative retrospective cohort study between May 2008- June 2008	NTS	N = 95 Parents of girls aged 11–17yo. Latino: 91%; Other: 9%

Note. NTS = No theory stated; TRA = Theory of Reasoned Action; TPB = Theory of Planned Behavior; HBM: Health Belief Model; U.S. = United States; HCPs= Health Care Providers; NHW= Non-Hispanic white.

Among the 15 studies conducted with African-American samples, eight (~53%) used a quantitative cross-sectional design, five (~33%) used a qualitative design, one (~7%) used a longitudinal design, and one (~7%) used a quantitative/qualitative design. The majority (~67%) of the studies did not report being informed by any theory. Five studies were informed by traditional health behavior theories, such as the Health Belief Model (n = 3; 21%) and the Theory of Planned Behavior (n = 1; 7%). Only one study (~7%) was informed by a combination of the Dissemination of Innovation Theory and the Community Based Participatory Marketing Method.

Studies conducted with an all or predominantly Latino sample were 26. Of these, 17 (~65%) were conducted with an exclusively Latino sample, fifteen (~58%) consisted of quantitative surveys, five (~19%) were qualitative studies, three (~12%) employed mixed methods, one (~4%) was a secondary analysis, and two (~8%) tested educational interventions. Six studies (23%) were informed by traditional health behavior change theories (i.e., the health belief model and the theory of planned behavior) with the others not reporting using any theory. Only one study was informed by a theory grounded in culture and three studies were informed by the Social Ecological Framework.

Next, we present the findings of the systematic literature review in five themes: (1) Awareness and knowledge of HPV and the HPV vaccine, (2) HPV vaccination barriers, (3) HPV vaccine acceptability and intentions to vaccinate, (4) HPV vaccine uptake, and (5) HPV vaccine series completion (Table 2).

Table 2.

Major findings related to African-American and Latino parental acceptance and uptake for the HPV vaccine.

Themes	Major findings
Awareness and knowledge of HPV and the HPV vaccine	• African-Americans with higher SES had higher HPV awareness. • Latinos who scored higher on U.S. acculturation had higher HPV awareness. Mixed findings regarding the direction of association between acculturation and HPV knowledge.
HPV vaccination barriers	• Among African-Americans, HPV vaccination barriers were insufficient information, lack of a HCP recommendation or hesitancy when recommending the vaccine, mistrust of HCP and pharmaceutical companies, perception that HPV vaccination is not needed, concern that daughter is too young for vaccination, religion, concern about vaccine effectiveness, cost, and lack of time. • Among African-Americans and Latinos, HPV vaccination barriers were sexuality-related concerns (concern HPV vaccination led to premarital sexual activity and that parents condoned premarital sex), concerns about vaccine safety, and low perceived risk of daughter acquiring HPV.
HPV vaccine acceptability and intention to vaccinate	• Acceptance rates varied more among African-Americans than among Latinos. • Among African-Americans, acceptability was associated with vaccine awareness, perception that the vaccine has cancer prevention benefits, vaccine being free of cost, religion, and social support. • Among African-Americans and Latinos, acceptability was influenced by parental views on sexuality, perceived daughter’s risk of acquiring HPV and cervical cancer, social norms, HCP recommendations, and perceived severity of being diagnosed with cervical cancer.
HPV vaccine uptake	• Latina mothers were twice more likely to accept HPV vaccination compared to mothers of other ethnicities. • Among African-Americans and Latinos, HPV knowledge was not related to vaccine uptake. Vaccine uptake was associated with receiving a HCP recommendation, being Latino, and perceived vaccine effectiveness and safety.
HPV vaccine series completion	• African-American and Latina adolescent girls are less likely to complete the vaccine series than non-Hispanic white adolescent girls. Series completion was associated with being older (16 years old), not being Black or Latino, and having a household income between 133% and <322% of the Federal Poverty line.

Note. SES = Socioeconomic status; U.S. = United States; HCP = Health Care Provider; HPV = Human papillomavirus.

3.1. Awareness and knowledge of HPV and the HPV vaccine

Bair et al. (2008) indicated that approximately 85% of Latina parents had not heard of HPV and were not aware of the HPV-cervical cancer link. Similarly, Fazekas et al. (2008) documented low awareness of the HPV vaccine (19%), and low correct knowledge of HPV (32%) in a sample of mostly African-American women from the rural south. Cates et al. (2009) corroborated these findings indicating low correct knowledge of HPV (29%) in a predominantly African-American sample.

Studies conducted post-licensure showed a reverse in the trend of low knowledge and awareness. Studies conducted with Latina mothers, who varied in SES, country of origin, urban versus rural residence, insurance, immigration status, and acculturation levels, indicated that knowledge and awareness levels ranged from moderate (43%) to high (80%) with levels becoming higher as years passed after licensure. By 2010, Wu et al. (2010) and Yeganeh et al. (2010) reported an awareness of HPV of 71%–73%, with 58% being aware of the HPV-cervical cancer link. Similarly, Hughes et al. (2009) found that HPV awareness and knowledge had increased greatly post-licensure in African-American parents. McRee et al. (2010) reported that 91% of parents had heard of the HPV vaccine and Allen et al. (2010) found that 88% of parents had heard about HPV and 65% about the HPV vaccine. However, even post-licensure, some studies composed of multi-ethnic samples reported that more Blacks (48%) and Latinas (39%) had never heard of the HPV vaccine than non-Hispanic Whites (25%) (Allen et al., 2010).

Importantly, among African-American and Latino parents, awareness and knowledge levels varied by socio-demographic characteristics. For example, in a cross-sectional survey of African-American male and female parents, HPV awareness was reported at 62% (Thompson et al., 2011) and those who were aware of HPV were female, employed, had some years of college, an annual income ≥$40,000, had a regular pediatrician, were younger than 41 years and had fewer children on average. HPV awareness in African-American women was also associated with a cervical cancer diagnosis. Those who were aware of HPV had either been diagnosed with HPV, cervical dysplasia or cervical cancer and 46% knew someone diagnosed with HPV or cervical cancer (Davlin et al., 2015; Thompson et al., 2011). An analysis of the 2010 National Health Interview Survey revealed an HPV vaccine awareness of 62.6%, with parents more likely to have heard of the HPV vaccine if they were parents of older children, non-Hispanic white, female, insured, English speakers, born in the U.S., had higher income and had a well-child visit in the last 12 months (Wisk et al., 2014). A similar HPV awareness level of 66% was found in a study that examined information sources for the HPV vaccine among African-Americans and Latinos (Baldwin et al., 2013). The study found that those who heard about the vaccine from their doctor were more likely to discuss it with close others compared to those who heard of it from media sources (Baldwin et al., 2013).

Among Latino parents, Gerend et al. (2013) assessed the influence of acculturation on knowledge. In this study, acculturation was measured as English language competence, identity, and cultural competence. Findings indicated that Latina mothers with lower English proficiency reported higher levels of knowledge compared to Latina mothers with higher English proficiency. However, this finding was contradicted by Kepka et al. (2014) who found that Latino parents who scored low on English proficiency were 8.5 times more likely to report insufficient information.

3.2. HPV vaccination barriers

Among Latino parents, the most common vaccination barriers were concerns that vaccination may condone sexual activity in preadolescent children (Gerend et al., 2013; Kepka et al., 2014, 2015; Kepka et al., 2012; Luque et al., 2012; Morales-Campos et al., 2013; Ramirez et al., 2014; Warner et al., 2014; Wu et al., 2010), concerns about safety of the HPV vaccine, and low perceived risk of children contracting HPV (Gilkey et al., 2014; Watts et al., 2009; Wu et al., 2010). Among African-American parents, the most common vaccination barriers were concerns about safety (Allen et al., 2012; Blackman et al., 2013; Brawner et al., 2012; Dorell et al., 2014; Hull et al., 2014; Rand et al., 2011; Sanders Thompson et al., 2012), concerns that HPV vaccination would lead daughters to engage in premarital sexual activity and give a false perception that parents condoned premarital sex (Allen et al., 2010; Brawner et al., 2012; Dorell et al., 2014; Dorell et al., 2011; Hull et al., 2014; Joseph et al., 2012), not having enough information about the vaccine (Allen et al., 2012; Guerry et al., 2011; Rand et al., 2011; Read et al., 2010), reporting not receiving a healthcare provider recommendation (Blackman et al., 2013; Guerry et al., 2011; Sanders Thompson et al., 2012), perceived provider hesitancy when recommending the vaccine (Hughes et al., 2011), mistrust of pharmaceutical companies (Allen et al., 2010, 2012), and mistrust of medical providers (Allen et al., 2012). The other most common vaccine acceptability barriers among African-American parents were lack of knowledge about HPV (Dorell et al., 2011; Hamlish et al., 2012; Fishman et al., 2014), perception that HPV vaccination is not needed (Dorell et al., 2011, 2014), low perceived risk of daughter’s acquiring HPV (Rand et al., 2011), religious denomination and frequency of religious service attendance (Shelton et al., 2013; Thomas et al., 2012), cost (Allen et al., 2010), lack of time (Brawner et al., 2012), concern that vaccination may create a false sense of protection against all HPV strains (Hamlish et al., 2012), concern about vaccine effectiveness (Dorell et al., 2014), and concern about daughters being too young to be vaccinated (Hull et al., 2014).

3.3. HPV vaccine acceptability and intentions to vaccinate

As early as 2007, studies emerged indicating that Latina mothers are twice more likely to accept vaccination compared to other ethnicities (Constantine and Jerman, 2007). Subsequent studies, indicated that despite low knowledge of HPV and the HPV vaccine, acceptability ranged from 80% to 97% (Bair et al., 2008; Sanderson et al., 2009; Watts et al., 2009). Importantly, Sanderson et al. (2009) documented acceptance as high as 90% for daughters and sons among a sample of Latina mothers. However, Wu et al. (2010) was the exception reporting a lower acceptance rate of 64% among a group of Latina mothers with access to health care services. Among Latina mothers, reasons for vaccination acceptance were belief in the importance of prevention to avoid regret, general positive attitudes towards other vaccines (Constantine and Jerman, 2007), perceived risk of daughters contracting HPV, beliefs in the importance of disease protection, and belief that the HPV vaccine is like any other vaccine (Bair et al., 2008; Sanderson et al., 2009; Wu et al., 2010).

Message framing and communication sources also influence intentions to vaccinate. Cox et al. (2010) found that different formats of presenting information (graphical HPV statistics, non-graphical HPV statistics and the presence or absence of a rhetorical question) influenced parents’ intention to vaccinate. Casillas et al. (2011) reported that hearing about the HPV vaccine from a family or friend increased the perception that the vaccine is effective compared to those who heard about the vaccine from a medical source.

Among African-American and Latino parents, intention to vaccinate was influenced by parental views on sexuality and daughters’ HPV risk, and by healthcare provider recommendations. Sadigh et al. (2012) indicated that Latino parents who conveyed acceptance of premarital sex among young adults were 2.45 times more likely to intend to vaccinate their children against HPV. A more recent publication (Lechuga et al., 2014) indicated that receiving a provider recommendation, worry about side-effects, believing that other parents have vaccinated their children, perceived severity of HPV, and worry that vaccination may encourage initiation of sexual relations emerged as a significant predictors of intentions among Latino parents.

Among African-American parents, acceptance varied more widely. African-American parents were motivated to accept HPV vaccination in anticipation of daughters’ sexual debut and to protect them from the stigma associated with contracting an STI (Hamlish et al., 2012; Perkins et al., 2010). A notable review with a sample of predominantly African-American women (Fazekas et al., 2008) revealed that 84% of women intended to vaccinate their daughters if the vaccine was free. Additionally, parents who knew more about HPV, had higher perceived risk and severity of acquiring HPV and cervical cancer had higher intentions to vaccinate their daughters. Read et al. (2010) in a study with a primarily African-American sample indicated that parents who were aware of HPV were 3.4 times more likely to accept the HPV vaccine for their daughters compared to parents who were unaware of HPV. Subsequent studies pointed to the importance of receiving a provider’s recommendation (Hamlish et al., 2012; Joseph et al., 2012; Litton et al., 2011; Thompson et al., 2011), social support for vaccination (Brawner et al., 2012) and perceiving the vaccine as having cancer prevention benefits (Hamlish et al., 2012; Perkins et al., 2010; Read et al., 2010).

Interestingly, religion was significantly associated with acceptability among African-Americans. For example, Thomas et al. (2012) reported that non-Baptists were 3.6 times more likely accept the HPV vaccine for their daughters compared to Baptists. Another study indicated that parents who had already vaccinated or intended to vaccinate their children were 2.7 times more likely to have a religion other than Baptist (Thomas et al., 2013). Shelton et al. (2013) also examined the influence of religion on HPV vaccine acceptance and found that parents with frequent religious services attendance were more likely to have decided against HPV vaccination than parents who did not attend services and Protestant parents were more likely to report that they had not vaccinated compared to other parents (Shelton et al., 2013).

3.4. HPV vaccine uptake

Among Latino parents, vaccination rates have steadily increased post-licensure. In 2009, Watts et al. (2009) documented a vaccination rate of 26% in their sample of Latinas. Wu et al. (2010) documented a vaccination rate of 27% among uninsured Latina mothers with access to health care services. This study was the first to report associations between vaccination status and reasons for and against vaccination. Results indicated that knowledge of HPV was unrelated to vaccination status. However, mothers of unvaccinated daughters were 1.6 times more likely to convey sexuality related concerns while mothers of vaccinated daughters were 1.2 times more likely to perceive their daughters as being at risk for HPV infection (Wu et al., 2010). Yeganeh et al. (2010) reported a vaccination rate of 37% among a predominantly Latino sample (80% reported having a regular health care provider). Importantly, the authors also report that 36% indicated to have refused the HPV vaccine. Regarding factors associated with vaccine uptake, results indicated that being Latino, belief in the effectiveness of the vaccine to prevent cervical cancer, and belief in the general safety of the vaccine emerged as predictors of vaccine uptake.

By 2012, studies continued to report low levels of vaccine uptake in Latina pre-adolescent daughters. Kepka et al. (2012b) reported a 35% vaccination initiation rate among primarily Spanish speaking Latina mothers living in a rural community. This study was the first to report a significant association between awareness of HPV and uptake. Among other predictors of uptake was the belief that daughter’s father approves of daughter’s vaccination and belief that only one dose is necessary. The emergence of these two factors as significantly associated with uptake is innovative as was authors’ use of the more expansive Social Ecological Framework of behavior change to inform survey content.

The first analysis of data from a large national survey was published in 2012 (Sadigh et al., 2012). Findings indicated a vaccination rate of 27% with families living below the poverty level being 4.43 times more likely to have initiated vaccination. Using a sample of low-income African-American and Latino parents who called a 2–1-1 Texas/United Way Helpline to receive information about cancer, Savas et al. (2012) documented a 29% vaccination rate. Factors associated with vaccination uptake were being Latino, receiving a doctor’s recommendation to vaccinate, and belief in the effectiveness of the vaccine to prevent cervical cancer.

Tsui et al. (2013) examined how the geographic location of safety health clinics influenced HPV vaccine initiation rates among a sample of predominantly Latina mothers. This was among the earliest studies to examine access among a sample of Latina mothers (51.6%) who had previously heard of the HPV vaccine (60.7%). The study reported an HPV vaccine initiation rate of 25% for adolescent girls, and reported that having an increased proximity to clinics was not associated with HPV vaccine uptake. Instead, daughters’ age, and having insurance was associated with higher HPV vaccine uptake.

Gerend et al. (2013) assessed sociocultural variables such as acculturation. Acculturation was measured as English language competence, identity, and cultural competence. In this study, only 18% of Latino parents reported initiating vaccination for their daughters. Variables associated with vaccination uptake were U.S. acculturation and a physician’s recommendation.

Reimer et al. (2013) study was the first to explore the influence of other sociocultural factors such as sexual activity and mother-daughter communication and the potential moderating influence of ethnicity. Results showed that vaccination uptake decreased by a factor of 0.77 when Latinas engaged in value-specific sexuality-related communication (in relation to moral, cultural, and religious values) and vaccination uptake increased a factor of 1.9 when non-Hispanic white mothers engaged in value-specific sexuality-related communication with their daughters. Across studies conducted with primarily African-American parents, Chao et al. (2009) analyzed the electronic health records of mother-daughter pairs, who had already initiated the HPV vaccine, and found that a mother’s Pap test history was associated with daughter’s HPV vaccine initiation (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.43, 1.52) regardless of race/ethnicity.

Subsequently, several studies that examined HPV vaccine initiation rates among African-American statewide samples were published. Reimer et al. (2013) examined HPV vaccine uptake correlates among parents who completed the 2008 Child Health Assessment and Monitoring (CHAMP) survey for North Carolina and found that 31.3% of parents reported that their daughters had received at least 1 dose of the HPV vaccine. Cates et al. (2010) also analyzed the 2008 North Carolina CHAMP survey and found a similar vaccine initiation rate (31%). Importantly, 46% of those who had initiated the HPV vaccine reported to have heard about the HPV vaccine from a healthcare provider and these parents were more likely to vaccinate.

Allen et al. (2010) analyzed data from a national survey of non-Hispanic white (48%), black (30%), and Hispanic (22%) parents to examine factors influencing daughters’ vaccination. Interestingly, regardless of awareness of the HPV vaccine, actual HPV vaccination rates were very low for all groups: non-Hispanic whites (12%), Blacks (11%) and Hispanics (15%). Similarly, Dorell et al. (2011) analyzed the NIS Teens 2008 and 2009 and reported an HPV vaccine initiation rate of 42.5% and the strongest factor associated with HPV vaccine initiation was a provider recommendation, daughter being older and having had an 11–12 year preventive visit, insurance status, and not receiving the HPV vaccine at a public facility. In other studies consisting of analysis of large national surveys, Lau et al. (2012) documented a low HPV vaccine initiation rate of 20% for a pooled sample of non-Hispanic whites, Latinos, and African-Americans, with non-Hispanic whites having a higher HPV vaccine initiation rate (61%) compared to Latinos (16%), and African-Americans (15%). In this study, parents who reported receiving a healthcare provider recommendation were 18 times more likely to initiate the HPV vaccine series. Laz et al. (2012) continued to document a low HPV vaccine initiation rate (28.9%), with non-Hispanic whites (29.6%), Blacks (26.9%) and Hispanics (31.1%) having similarly low HPV vaccine initiation rates. The factors associated with vaccine initiation included having an influenza vaccine in the past year and parental awareness of the vaccine.

Polonijo and Carpiano (2013) conducted a theory informed analysis of data from a national survey. The overall HPV vaccine initiation rate for the multi-ethnic sample of White, Black, and Hispanic adolescent girls was 38.9%. Importantly, this study found that girls in middle or low-income households had 25% lower odds of initiating the vaccine compared to girls from high-income households. Black adolescent girls had 22% lower odds of initiating the vaccine compared to non-Hispanic white adolescent girls. Additionally, the odds of receiving a provider’s recommendation for the HPV vaccine was significantly lower for black (27%) and Hispanic (14%) adolescent girls than non-Hispanic white adolescent girls. In 2013, Kester et al. (2013) documented an HPV vaccine initiation rate of slightly more than half (51.1%). Unlike the Polonijo and Carpiano (2013) study however, socioeconomic and demographic factors were not associated with vaccine initiation.

3.5. HPV vaccine series completion

Yeganeh et al. (2010), to our knowledge the only study reporting on HPV vaccine completion rates in a sample of primarily Latina mothers, indicated that 37% of mothers had initiated vaccination for their daughters and of these, 43% and 26% reported uptake of two and three doses, respectively.

The earliest study to document HPV vaccine completion rates in primarily African-American samples was published by Dorell et al. (2011). In this study, 40% of adolescent girls initiated the HPV vaccine and 53.3% of those completed the series. Black and Hispanic adolescent girls were less likely to complete the series than non-Hispanic white girls. The HPV vaccine series completion rate for non-Hispanic whites (60.4%) was higher than that of Blacks and Hispanics (46% and 40.3%). Factors associated with HPV vaccine completion was being 16 years old, not being Black or Latino, and having a household income of 133% to <322% of the Federal Poverty Level. Laz et al. (2012) indicated that of 28.9% who had initiated the vaccine, 49% completed the three dose series. The study also documented that of those who initiated the vaccine, 16.1% of non-Hispanic white, 10.9% of black, and 12.3% of Latina adolescent girls had received all doses.

Polonijo and Carpiano (2013) reported a completion rate of 21.7% and a positive association between completion and higher maternal education. Also, adolescents in middle and low-income households had significantly lower odds (23%–25%) of completing the series. Additionally, estimates for black adolescents indicated a 34% lower odd of completing the vaccination series, while the estimate for Latino adolescents was 13%. Kester et al. (2013) reported a similarly low HPV vaccine completion rate of 38.3%. In this study, black and Latina girls were also significantly less likely to complete the 3-dose series than non-Hispanic white girls.

4. Discussion

African-Americans and Latinos are disproportionately affected by certain HPV-related cancers (Jemal et al., 2013). The unveiling of the HPV vaccine has been hailed as a remarkable public health achievement with the potential to reduce disparities in HPV-associated cancers. Unfortunately, completion rates are well-below the 70% completion rate needed to achieve herd immunity (Kim and Goldie, 2008) and large ethnic disparities exist in completion rates. Our literature review indicated that awareness about HPV and the vaccine varies by parents’ demographic characteristics. There is an association between higher SES and awareness among African-American parents and acculturation and awareness among Latino parents. However, findings were mixed regarding the direction of association between acculturation and knowledge among Latino parents. It is important to note that acculturation has been assessed primarily as English proficiency and English proficiency is strongly associated with SES. It will be important to replicate research on acculturation to include other facets of acculturation such as ethnic identity and cultural knowledge for both U.S. and native culture as done by Gerend et al. (2013). Findings indicated that awareness is not enough to motivate vaccination as higher levels of awareness increased over time to a greater extent than actual vaccination rates. In addition, some studies found no association. In fact, research indicates hesitancy to vaccinate in a good proportion of parents who are aware of the vaccine and the HPV-cervical cancer link. Notwithstanding, research has not explored why Latino and African American parents may be less aware/knowledgeable than other ethnic groups. A possible explanation is lack of targeted communication campaigns in sources considered credible by Latino and African-American parents. For example, research documenting the credibility of distinct sources has been sparse. Our review indicated that among Latinos, having heard about the HPV vaccine from health care providers increased uptake compared to learning about the vaccine from other sources. Recent research suggests that trust in information sources is an influential factor in parental vaccination yet this type of research has been sparse in the U.S. (Yaqub et al., 2014).

Regarding vaccination barriers, concerns that HPV vaccination may lead daughters to engage in premarital sex and provide a false perception that parents condoned premarital sexual activity emerged. This finding is in contrast with findings of research conducted with non-Hispanic white parents for whom sexuality-related concerns are low (Brewer et al., 2011; Marlow et al., 2009). This contrast in findings suggests other fruitful avenues of parental acceptability research to be pursued among African-Americans and Latinos. For example, few research has inquired in depth about the attitudes and values underlying sexuality-related concerns and how best to address them in behavioral interventions. Importantly, both African-Americans and Latinos share a culture of silence regarding sexuality-related communication within their family and community (Harris, 2010; Meneses et al., 2006; West, 1993). Such culture of silence may underlie sexuality-related concerns. Importantly, continuing with research informed solely by prominent health behavior change theories which focus on rational decision making that is devoid of cultural context and centers on attitudes towards the vaccine itself may take researchers into an unfruitful path regarding the discovery of important factors to consider and address in interventions to promote child STI vaccines in African-American and Latino parents. Furthermore, low perceived risk of child contracting HPV also emerged as a shared barrier across both ethnic groups. Sexuality-related concerns may underpin low perceived risk of child contracting HPV. Low perceived risk of child contracting HPV may be closely associated with the belief that children for whom vaccination is currently recommended are too young to become sexually active and hence are at low risk. Furthermore, for African-American parents, religious beliefs may underpin sexuality-related concerns by promoting negative views about adolescent sexuality. These hypotheses need to be corroborated in future research and if so, interventions need to address sexuality-related concerns directly including educating parents about the low probability rate that they will accurately predict the timing of their children’s sexual debut.

Concerns about safety also emerged as a shared barrier for African-Americans and Latinos. The U.S. Latino population is a heterogeneous group regarding generational status, immigration patterns, country of origin, language, and ethnic identity. It is important to continue research with diverse segments of the U.S. Latino population. For example, vaccination mandates are well-regarded in Mexico by the general population. However, the extent to which this general positive attitude generalizes to Latinos born in other countries has not been adequately researched. In addition, the U.S. Latino population varies regarding generational status and U.S. born Latinos, who may be more acculturated to the U.S. culture, may hold different attitudes. Surprisingly, acculturation has featured poorly in research on Latino parental HPV vaccine acceptability.

It is important to note that other barriers cited by African-Americans may be closely associated with safety concerns, such as not having enough information, not receiving a provider recommendation or receiving a hesitant recommendation, mistrust of medical providers and pharmaceutical companies, and concern about effectiveness. The introduction of the HPV vaccine in the U.S. has been shrouded in controversy (Keelan et al., 2010; Tozzi et al., 2010), which has created undue concern about safety (Wailoo et al., 2010). Controversy may have been particularly salient for African-American parents whose experience with the healthcare system is often negative (Williams and Wyatt, 2015). To date, research has focused on elucidating the proportion of parents who convey safety concerns and the influence of such concerns on vaccination intentions and uptake. Little research has been conducted to elucidate beliefs and attitudes that may underpin such concerns such as mistrust of U.S. entities promoting the vaccine. Researching mistrust may be another fruitful avenue to pursue to inform the design of HPV vaccine promotion interventions targeting African-Americans in particular.

Regarding vaccination acceptance and intentions, studies with Latino parents revealed that acceptability is high and vaccination intentions associated with the vaccine’s cancer preventive benefits, low perceived risk of negative side effects, believing that other parents are vaccinating their children (norms), positive attitudes towards vaccines in general, perceived risk of daughter’s acquiring HPV, acceptance of pre-marital sex, low worry that vaccination may encourage initiation of sexual relations, and receiving a provider’s recommendation. These findings lend support to findings pointing to vaccination barriers. However, more research is needed to uncover which of these factors emerge as the most important in vaccination acceptance. Importantly, no research has addressed the potential interactive nature of predictors of vaccination intentions.

Regarding acceptability, the rate varied more widely among African-Americans compared to Latinos. Acceptance and intentions among African-Americans were associated with awareness of HPV, perceived risk of acquiring HPV and cancer, perceived severity of cervical cancer, and receipt of a provider’s recommendation. Among African-Americans, religion emerged as a factor influencing HPV vaccine acceptance. However, acceptability and intentions are imperfectly related to actual behavior. Consequently, findings regarding predictors of uptake are especially important.

Regarding specific predictors of uptake among Latino parents, belief in the effectiveness of the vaccine and safety, belief that father of the child approves of the vaccine, receiving a doctor’s recommendation to vaccinate, U.S. acculturation, sexuality-related communication between mother and daughter, and norms are significantly associated with uptake. For African-American parents, receiving a pap-test, being aware of the HPV vaccine, receiving a health care provider recommendation, daughter’s age, daughter attending a preventative health care appointment, insurance, having received the influenza vaccine in the prior year, social support, and SES were associated with vaccine uptake. Significant predictors of vaccination uptake mirrored the predictors of intentions. This may be the result of researchers continuing to follow traditional health behavior change theories to inform uptake studies. However, important findings emerged that point to new research avenues. First, among Latino parents, the research findings regarding the link between knowledge and awareness of HPV and vaccination uptake remain mixed. Among African-Americans, the link between religion and HPV vaccine uptake also remain mixed. Results of studies documenting the influence of sociocultural variables rather than properties of the vaccine (e.g., effectiveness and side-effects) have shown interesting results pointing to the importance of context such as consideration of father of the child in the decision-making process, communication about sexuality between mothers and daughters, mistrust of healthcare providers and pharmaceutical companies, social support for vaccination and norms. These findings suggest that future research with Latinos and African-Americans need to expand on the role of sociocultural aspects and be informed by theories other than prominent health behavior change theories. Interventions focusing only on changing attitudes towards safety and effectiveness are likely to be minimally effective if individuals are making vaccination decisions by considering other aspects also.

For both African-Americans and Latinos, receiving a provider’s recommendation was strongly associated with uptake. The influence of norms for Latinas further underscore the importance of a provider’s recommendation because as more parents decide to vaccinate their children following recommendations, social norms will change further increasing uptake. In addition, social network interventions to promote HPV vaccination among Latinas may be particularly effective. Social network interventions to promote prevention for other STIs among Latinas have shown promise (Ramos et al., 2010; Ramos et al., 2009). Similarly, social support networks are an integral part of African-American culture (McAdoo and Younge, 2008). Social support from network members influence African-Americans’ HPV vaccine acceptance. However, studies on the type of social support and the role of support networks on African-Americans HPV vaccine acceptance are limited.

For African-Americans, socio-demographic characteristics associated with uptake such as pap test history, having received the influenza vaccination, having had a well-child visit, insurance, and cost underscore the key role of the health care provider in recommending the vaccine during other preventative health care visits. Regarding vaccination completion, African-Americans have the lowest completion rates compared to Latino and non-Latino white parents. However, little research has been conducted indicating potential reasons.

4.1. Future research

Current academic health promotion discourse (Pasick et al., 2009) points to the importance of expanding health behavior change theories to incorporate culture-related variables as these may play a prominent role in behavior change decision-making when compared to person-centric variables such as attitudes toward the attributes of the behavior in question. Importantly, research indicates that sexuality-related concerns are prominent in parental acceptance of the HPV vaccine in ethnic minority populations and little research has been conducted to understand the nature of such concerns. Future research could benefit by focusing on culture-centered theories to unpackage sexuality-related normative concerns among African-Americans and Latinos to explore its connection to religion and related factors.

It is interesting to note few studies have investigated factors associated with vaccinating sons. Research is moving in this direction with publications increasing steadily after the ACIP approved the vaccine for males in 2009, albeit too few to warrant a review of the literature. The few existing studies indicate that a provider’s recommendation also influence uptake and in the case of Latinos, Spanish-speaking Latinos convey greater intent to vaccinate boys compared to English-speaking Latinos (Reiter et al., 2014). This finding suggests that the time is ripe to conduct further research on culture-related factors associated with vaccination uptake for male children. In particular, what is it about the culture of origin of U.S. Latino immigrants that promote positive attitudes towards vaccines?

Furthermore, our review also pointed to the dearth of interventions to promote HPV vaccination among African-Americans and Latino parents. The few intervention studies included in this review tested different risk presentation formats (Cox et al., 2010), radionovelas among Latinos (Kepka et al., 2011; Kepka et al., 2012), a gain versus loss message framing intervention (Lechuga et al., 2011), and a skills-based intervention to increase HPV vaccine uptake among African-American adolescents and their parents (Brawner et al., 2012). More culturally tailored and theory guided intervention studies to increase HPV vaccine acceptance among African-American and Latino parents are needed.

Lastly, it is imperative that interventions be developed to also target HPV vaccination completion. Barriers to completion among the general population seem to center around logistical issues such as lack of reminder systems in clinics (Chao et al., 2015), inadequate vaccine stock in health care settings given the high cost of the vaccine, (Brisson et al., 2013) and the quality of a provider’s recommendation. Completion is higher in patients who attend a pediatrics clinic compared to family or internal medicine or OBGYN departments (Rubin et al.,, 2012). Future research could shed light on the approach taken by pediatricians and develop educational interventions to train other providers in the use of successful HPV vaccine promotion strategies. However, future studies should also attempt to corroborate that the abovementioned factors associated with completion rates generalize to ethnic minorities.

4.2. Limitations

Selection of articles for review was based on how closely the study objective was related to the review’s objective and the racial/ethnic makeup of the study samples. Importantly, the studies in this review were selected based on their content instead of their methodological rigor. Another limitation is that the designs of the studies in this review were primarily quantitative cross-sectional, secondary analyses or qualitative descriptive. Therefore, studies using more rigorous designs may be needed to prove causation (Brink and Wood, 1997). In addition, we describe the factors that have emerged as significantly associated with vaccination acceptance and uptake and we did not weigh which of these factors may be more important. Regardless of these limitations, this systematic literature review will help guide future research on HPV vaccine acceptability that is conducive to the design of impactful interventions to promote the vaccine among African-Americans and Latinos. Failing to develop impactful interventions to reverse the trend of below optimal initiation and completion rates may result in the exacerbation of ethnic disparities in cervical and other HPV-related cancers.

5. Conclusions

Findings from this review point to the need for more studies with African-Americans and Latinos using alternative theoretical frameworks grounded in culture. Our findings indicated that there are distinct barriers among African-Americans and Latinos compared to non-Latino parents such as sexuality-related concerns, religion derived concerns, and mistrust.

A systematic review conducted in 2014 by the Community Preventive Services Task Force, an independent, nonfederal unpaid panel of public health and prevention experts, sheds light on the effectiveness of community-based interventions to promote other immunizations among medically underserved families. Findings indicate that implementation of a combination of the following strategies (to increase community demand and facilitate access) increases vaccination rates an average of 14 percentage points: client reminder and recall systems, manual outreach and tracking, client or community-wide education, client incentives, client-held paper immunization records, case management, increases in availability/access in health care settings or by home visits, and by reducing out of pocket cost (Community Preventive Services, 2015). In the interest of accelerating the uptake of the HPV vaccine we advocate for the introduction of these strategies along with research on the most effective strategies to reduce the specific barriers yielded in this review.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.socscimed.2016.04.028.