Latinx Immigrant Mothers’ Perceived Self-Efficacy and Intentions Regarding Human Papillomavirus Vaccination of Their Daughters

Abstract

Objective:

Racial and ethnic disparities persist in cervical cancer cases, 90% of which are caused by the human papillomavirus (HPV). Suboptimal vaccine uptake is problematic, particularly among Latinx women, who have the highest cervical cancer incidence compared to other racial/ethnic groups. We examined the association of self-efficacy and HPV vaccination intention among Latinx immigrant mothers of unvaccinated 9–12-year-old girls.

Methods:

An interview-administered survey assessed baseline sociodemographic information, knowledge and perceived risk of cervical cancer and HPV, self-efficacy, and intention to vaccinate among 313 Latinx immigrant mothers in Alabama from 2013–2017 prior to the implementation of an intervention to promote HPV vaccination.

Results:

Participants were, on average, 35 years old, with 9 years of education, and had lived in the U.S. for 12 years. Mothers who perceived their daughters were at risk of HPV infection were more likely to be vaccine intent than their hesitant counterparts (p<0.001). Vaccine hesitancy was more common in those with lower education, low HPV and cervical cancer knowledge, and lower perceived self-efficacy scores (p<0.001). Self-efficacy was associated with vaccine intention when controlling for other variables (p<0.001). The only variable associated with self-efficacy was HPV awareness (p=0.001).

Conclusions:

Programs promoting HPV vaccination among Latinx immigrants should include educational components regarding risks of HPV infection and cervical cancers in addition to information regarding access to vaccination services. Knowledge of risks and access may heighten perceptions of self-efficacy and improve vaccine uptake among this population.

INTRODUCTION

Knowledge of the pathogenesis of cervical cancer has led to great improvements in morbidity and mortality from this disease (National Cancer Institute, 2020). However, racial/ethnic disparities related to this common human papillomavirus (HPV)-related cancer persist (Centers for Disease Control and Prevention, 2018). In particular, Latinx women exhibit the highest rate of new cervical cancer diagnoses in the U.S., with just over 9/100,000 women compared to 7/100,000 among their White counterparts (Centers for Disease Control and Prevention, 2018). Among reasons for this disparity are lack of knowledge/awareness of cervical cancer or of HPV (Coronado et al., 2013; Drewry, Garcés-Palacio, & Scarinci, 2010; Garcés-Palacio & Scarinci, 2012; Luque et al., 2017) and lack of screening (Luque et al., 2017; Rojas et al., 2017). Since 2006, vaccination against HPV has been approved and marketed to pre-adolescents and adolescents as a recommended preventive measure for HPV-associated cancers (Petrosky et al., 2015). However, the fact that only 51% of adolescents in the U.S. are up to date with the vaccine series (Walker et al., 2019) indicates suboptimal implementation. This can be problematic considering over 90% of cervical cancer diagnoses have an association with HPV infection (Centers for Disease Control and Prevention, 2018) and the vaccine can diminish future incidence of this malignancy (Markowitz et al., 2019).

Parental acceptability has been a targeted focus of improving HPV vaccination rates in pre-adolescents and adolescents (Garbutt et al., 2018; Groom et al., 2017; Reno et al., 2019). As gendered roles in various cultures differ, it is important to consider the gender-specific scripts traditionally found within families. In traditional Latinx families, studies have shown women typically take the caregiving role in the family (Ruiz, 2005) and that family health decisions typically fall under this role (Martinez, Rhee, Blanco, & Boutelle, 2017; Morales-Campos, Markham, Peskin, & Fernandez, 2013). While Latinx adolescents have higher rates of HPV vaccination than adolescents of other races/ethnicities (Walker et al., 2019), there are differences in vaccine uptake and acceptability between U.S.-born and immigrant families, with some researchers finding that acceptance rates were higher among those in the U.S. the longest (Kepka, Ding, Bodson, Warner, & Mooney, 2015). However, other studies determined that length of time in the U.S. did not significantly impact uptake until after participants completed an HPV educational intervention (Foley et al., 2015).

According to the Health Belief Model (HBM), an individual’s perceived risk of contracting a medical condition and their perceived self-confidence to complete a healthy behavior (self-efficacy) are important tenets that influence the ability to carry out a preventive behavior (Rosenstock, Strecher, & Becker, 1988). In the case of HPV vaccination, there is an assumption that a woman would have to perceive HPV and cervical cancer as threats to their children and be confident in their ability to complete the vaccination series. Multiple studies have focused on factors associated with differences in individuals’ perceptions of risk of developing cervical cancer (Coronado et al., 2013; Gibson, Gage, Castle, & Scarinci, 2019; Luque et al., 2017). In fact, a recent study found that among adolescents’ guardians, higher self-efficacy and lower perceptions of HPV-related cancer risk impacted decisions to abstain from vaccination, but the study did not report results for Latinx persons nor did they include Spanish-speaking participants (Myhre, Xiong, Vogel, & Teoh, 2020).

Multiple studies have focused on factors associated with differences in perceived risk of individuals for early detected cancers such as cervical cancer (Hay et al., 2014; Taber & Klein, 2016; Waters, Hay, Orom, Kiviniemi, & Drake, 2013; Waters, Kiviniemi, Orom, & Hay, 2016). To our knowledge, there have been limited studies to determine factors that are associated with self-efficacy as this construct has been included as an independent variable rather than a dependent variable in most studies.

Given that Latinx women are at a higher risk of developing cervical cancer and the aforementioned disparities between U.S.-born and immigrant parents, we were specifically interested in the perceptions of HPV vaccination among Latinx immigrant mothers. The purpose of this study was two-fold: (1) to examine the association between self-efficacy and HPV vaccination intent among Latinx immigrant mothers of unvaccinated 9–12-year-old girls; and (2) to examine factors associated with mothers’ perceived self-efficacy to vaccinate their daughters against HPV.

METHODS

Study Design

We examined baseline data from a research study that evaluated the efficacy of a theory-based, culturally relevant intervention to promote HPV vaccination among daughters of Latinx immigrant mothers between the ages of 9–12 years living in an urban area in Alabama (Scarinci, Hansen, & Kim, 2020). The protocol was approved by the Institutional Review Board at The University of Alabama at Birmingham and mothers provided signed consent; daughters signed assent.

Theoretical Framework

The Health Belief Model (HBM) (Rosenstock, 1990; Rosenstock et al., 1988) guided the preliminary formative assessments, followed by the development and implementation of the intervention. The HBM is based on the premise that an individual’s beliefs drive changes in health behaviors. In the case of HPV and cervical cancer, the HBM would suggest that for changes to occur, individuals must believe: 1) they are vulnerable to HPV infection and/or cervical cancer); 2) serious consequences can result from HPV exposure; 3) receiving an HPV vaccination will reduce the vulnerability to the threat; 4) the benefits of vaccination outweigh the potential costs; and 5) they have confidence in their ability (self-efficacy) to engage in the preventive action (vaccination of their daughters). The concept of self-efficacy used in the HBM stems from Bandura’s work in social cognitive theory (Bandura, 1997, 1998).

Participants

Participants were Latinx immigrant mothers and their 9–12-year-old daughters. Inclusion criteria were the following: residence in Alabama, Latina immigrant, having at least one daughter between the ages of 9 and 12 years, no personal history of cervical cancer, daughter(s) not having been vaccinated against HPV (to their knowledge), and no previous participation in an HPV or cervical cancer education/vaccination effort. Alabama has been classified as an “Latinx emerging state” given the major influx of Latinx immigrants in the past 25 years (U.S. Census Bureau, 2011). Our studies have shown that the majority of Latinx immigrant women in Alabama tend to be from Mexico, be young (approximate mean age of 30 years of age), and have limited educational attainment, with the majority having less than high school education (Cherrington et al., 2015; Drewry et al., 2010; Redding et al., 2010; Scarinci, Beech, Kovach, & Bailey, 2003; White et al., 2017; White & Scarinci, 2015)

This study commenced in 2013; however, the formative assessments guiding the development of the questionnaire and intervention were part of a grant submission in 2011, a time when the HPV vaccination was recommended by the ACIP for girls only (Centers for Disease Control and Prevention, 2010). While this recommendation has since been expanded to include boys, the focus of this study remained on girls per the study protocol.

Procedure

Based on methods implemented in our previous studies among Latinx persons in Alabama (Garcés-Palacio & Scarinci, 2012; Scarinci, Beech, Kovach, & Bailey, 2003; Scarinci, Garcés-Palacio, Morales-Alemán, & McGuire, 2016), we determined locations that had not reported HPV or cervical cancer prevention/control efforts and focused our recruitment efforts there. The aforementioned research studies found success recruiting participants within small enclaves. Thus, our study, in a similar fashion, recruited participants from apartment complexes, trailer parks, and/or neighborhoods with a large percentage of Latinx residents. In order to confirm that there were sufficient eligible participants in these locations, staff conducted a door-to-door “census,” which covered basic demographic variables and willingness to participate in a health-related study in the future. Staff determined eligibility and willingness to participate in the study and proceeded with enrollment, consenting procedures, and completion of interviewer-administered questionnaires. All participants signed written consent forms, available in Spanish.

Measures

Assessment measures were developed or adapted through extensive formative assessments and used in previous studies with Latinx immigrants (Drewry et al., 2010; Garcés-Palacio & Scarinci, 2012; Scarinci et al., 2003). Most of the measures used were previously translated to Spanish. For the additional items that needed translation, we used the recommended procedures of translation from English to Spanish and then back-translation by a different individual. The questionnaires were administered in Spanish using a face-to-face interviewing format by staff.

The outcome variables were mothers’ vaccine intention and perceived self-efficacy to complete vaccination series, operationalized as a self-efficacy score. For vaccine intention, mothers answered “yes,” “no,” or “maybe” to the question: “Would you have your daughter between the ages 9 to 12 vaccinated with the HPV vaccine?” Given the low response of mothers who reported “no,” these responses were combined with the mothers who answered “maybe” and defined as the vaccine hesitant group. The three separate questions comprising the variable “perceived self-efficacy” asked about the mothers’ confidence in their overall ability, time, and money to have their daughters vaccinated against HPV. We have used this measure in previous studies, as mentioned above; a reliability analysis was conducted with Cronbach’s alpha (α=0.81) to determine internal consistency of the three self-efficacy questions. Self-efficacy questions were scored based on the following responses: an answer of “sure” as three points, “more or less sure” as two points, and “not sure/I don’t know” as one point. Scores from the three questions were then added together to create a perceived self-efficacy score with a maximum of nine and a minimum of three points.

Independent variables included sociodemographic characteristics: age, time lived in the U.S., years of education completed, employment status, and monthly household income. Information about the mothers’ and daughters’ healthcare was also collected, including health insurance status and the place where they received medical care. Questions that assessed knowledge, awareness, worry, who makes the vaccination decision, and perceived risk about both cervical cancer and HPV that the mother interpreted for herself and her daughter were also analyzed. Perceptions of cervical cancer were assessed with, “Have you heard about cervical cancer or cancer of the mouth of the womb before?” and “Do you believe that you are at risk of having cervical cancer?” Responses included “Yes,” “No,” and “I don’t know/I’m not sure” (Garcés-Palacio & Scarinci, 2012).

HPV knowledge consisted of the interpretation of 11 statements about HPV infection. Items included topics such as HPV infection, cancer risks, transmission, treatment, and awareness of a vaccine (Drewry, Garcés-Palacio, & Scarinci, 2010). A Cronbach’s alpha was also conducted on these statements to determine internal consistency of the questions (α=0.66). Correct answers were awarded one point while incorrect answers or “I don’t know” were recorded as zero points. The points from each question were then added together to create an HPV knowledge score with the maximum possible score being 11 and the minimum being zero. However, these questions were only asked of mothers who indicated having heard of HPV.

Analysis

Sociodemographic characteristics and perceived risk of HPV and cervical cancer among the two groups of mothers were summarized by presenting descriptive statistics, such as sample means with variances and frequencies. Bivariate associations were estimated by using t-tests and chi-square tests appropriately. A multivariable logistic regression model with forward selection was used to evaluate associations of four variables (“perceived self-efficacy,” “HPV awareness,” “perceived risk of HPV in daughter,” and “responsibility for vaccine decision”) with HPV vaccination intention (dependent variable) adjusted for other covariates, including marital status, years of education completed, household income, perceived risk of cervical cancer, self-perception of HPV infection, perceived risk of HPV in self, and perceived worry about HPV infection in daughter. The reference group for the DV and the perception/awareness questions was “don’t know/not sure”. “Mothers only” was the reference group for the “responsibility for vaccine decision” variable (as opposed to both parents).

A multivariate linear regression model was estimated to assess participants’ self-efficacy scores (DV) with the following IVs: time in the U.S. (months), number of daughters, number of sons, average household income, daughters’ place of care, HPV awareness, daughters’ health insurance status, responsibility for vaccine decision, perceived self-risk of cervical cancer, perceived exposure to HPV, perceived self-risk of HPV, worry of HPV in daughter, and perceived risk of HPV in daughter. The reference group for questions of perceptions of cervical cancer/HPV in both herself and daughter as well as HPV awareness was “don’t know/not sure.” For daughter’s place of care, the reference group was “private doctor/clinic.” For vaccination responsibility, it was “mother only,” as opposed to the decision being made by both the mother and father. All statistical analyses were conducted with SPSS version 25 (IBM Corp., 2019) with α=0.05, two-tailed test.

RESULTS

The total sample was 313 mothers, most of whom were from Mexico. Of these mothers, 62.6% were hesitant to vaccinate their daughters, while 37.4% intended to vaccinate their daughters. The majority of mothers were married or living with a partner (89.7%), and were an average of 35.00 ± 5.59 years of age. They completed about 8.77 ± 3.08 years of education and had lived in the U.S. for approximately 150.80 ± 50.76 months. Average income in a household per month was $356.15 ± 249.63 dollars. Most participants had heard of HPV (53.7%), but the majority indicated that they did not know if they were at risk for cervical cancer (60.1%). While over 80% were worried about HPV infection in their daughters, 40.9% of mothers indicated they did not know if their daughters were at risk of infection.

Mothers were compared to each other based on their vaccine intention (see Table 1). Those intending to vaccinate were found to have completed more years of school compared to those hesitant (9.28 ± 3.23 and 8.46 ± 2.94 years, respectively, p=0.03). In addition, HPV knowledge scores were higher among mothers who planned to vaccinate their daughters compared to those hesitant to do so (7.53 ± 2.54 versus 5.78 ± 2.38 points, p<0.001). Mothers who intended to vaccinate had a perceived self-efficacy score of 7.29 ± 1.53 points; this was higher than those hesitant to vaccinate (5.54 ± 1.43; p<0.001). Of mothers intending to vaccinate, 94% were worried about their daughters’ contracting HPV in the future while over 75% of hesitant mothers were worried about future HPV infection in their daughters. The majority of mothers intending to vaccinate perceived their daughters at risk for HPV (76.1%), while the majority of hesitant mothers indicated “do not know” if there was a risk of HPV in their daughters (54.6%).

Table 1:

Demographics of Sample Population as a Whole and by HPV Vaccination Intention (N=313)

	Total	Intent (n=117)	Hesitant (n=196)	p
Age (years)1	35.00 (5.59)	35.42 (5.61)	34.75 (5.57)	0.31
Months in United States1	150.80 (50.76)	152.86 (58.28)	149.57 (45.80)	0.60
Education (years)1	8.77 (3.08)	9.28 (3.23)	8.46 (2.94)	0.03
Monthly Household Income (US$)1	356.15 (249.63)	388.78 (320.65)	337.18 (195.48)	0.13
Number of Children1
Daughters	2.02 (0.92)	2.05 (0.89)	2.00 (0.95)	0.63
Sons	1.14 (1.01)	1.08 (1.02)	1.17 (1.01)	0.42
HPV Knowledge Score1,2	6.63 (2.60)	7.53 (2.54)	5.78 (2.38)	<0.001
Self-Efficacy Score1 Marital Status3	6.19 (1.69)	7.29 (1.53)	5.54 (1.43)	<0.001
Single	6.7	6.8	6.6
Living Together	33.2	42.7	27.6	0.03
Married	56.5	48.7	61.2
Separated/Divorced	3.5	1.7	4.6
Widowed	--	--	--
Employment Status3
Full-time Job	20.1	21.4	19.4
Part-time Job	31.3	30.8	31.6	0.88
No Job	3.5	2.6	4.1
Housewife	45.0	45.3	44.9
Mother’s Place of Care3				0.27
Private Doctor’s Office/Clinic	16.3	17.9	15.3
Public Medical Clinic	54.0	47.0	58.2
FQHC	14.4	16.2	13.3
Other	15.3	18.8	13.3
Daughter’s Place of Care3				0.73
Private Doctor/Clinic	52.7	52.1	53.3
Public Medical Clinic	31.9	35.0	30.3
FQHC2	11.5	9.4	12.8
Other	3.5	3.4	3.6
Has Health Insurance-Mother3	9.9	7.7	11.2	0.30
Has Health Insurance-Daughter3	78.0	78.4	78.1	0.94
HPV Awareness
Yes	53.7	69.2	44.4
No	18.2	15.4	19.9	<0.001
Don’t Know	28.1	15.4	35.7
Perceived Self-Risk of Cervical Cancer3
Yes	16.3	25.9	10.8	0.001
No	22.7	25.0	21.6
Don’t Know	60.1	49.1	67.5
Perceived Exposure to HPV3
Yes	16.3	16.2	16.4	0.39
No	38.0	42.7	35.4
Don’t Know	45.4	41.0	48.2
Worry HPV3
Yes	64.5	70.1	61.9	0.15
No	19.8	19.7	20.1
Don’t Know	15.0	10.3	18.0	0.01
Perceived Self-Risk of HPV3
Yes	8.9	12.8	6.7
No	53.0	59.0	50.0
Don’t Know	37.4	28.2	43.3
Worry HPV in Daughter3				<0.001
Yes	83.1	94.0	76.5
No	3.8	0.9	5.6
Don’t Know	13.1	5.1	17.9	<0.001
Perceived Risk of HPV in Daughter3
Yes	51.8	76.1	37.2
No	7.3	6.0	8.2
Don’t Know	40.9	17.9	54.6	0.01
Responsibility for Vaccine Decision3
Mother	24.9	34.2	19.4
Mother and Father	64.2	55.6	69.4
Other	10.9	10.3	11.2

¹Mean (Standard Deviation)

²Only mothers who answered Yes to HPV Awareness were assessed for HPV Knowledge.

³Percentage

Abbreviations: HPV=human papillomavirus; FQHC=Federally Qualified Health Center Bold type indicates statistical significance

A logistic model predicting binary status of hesitancy was developed to identify factors associated with HPV vaccination intention. Predictors in the final model included: perceived self-efficacy score, HPV awareness, mothers’ perceived risk of HPV in their daughters, and responsibility for vaccine decision (see Table 2). In particular, mothers who perceived their daughters at risk of HPV were more likely to exhibit vaccination intention than those who reported “do not know/not sure” (OR=4.78, CI 2.47 to 9.27, p<0.001). Mothers who reported awareness of HPV were more likely to intend to vaccinate compared to those who did not know of HPV (OR=2.59, CI 1.21 to 5.58, p=0.02). Furthermore, mothers who believed they and the father were both responsible for deciding if their daughter should get the vaccine were less likely to intend to vaccinate compared to mothers who felt it was a decision to make on their own (OR=0.46, CI 0.23 to 0.92, p=0.03). Finally, for each point increase in a mother’s self-efficacy score, she was more likely to have intention of HPV vaccination for her daughter (OR=2.16, CI 1.70 to 2.74, p<0.001).

Table 2.

Logistic Regression Model Predicting HPV Vaccination Intention¹ (N=313)

	OR	95% CI	p
Perceived Self-Efficacy Score2	2.16	1.70 to 2.74	<0.001
HPV Awareness3
Yes	2.59	1.21 to 5.58	0.02
No	1.62	0.62 to 4.25	0.33
Perceived Risk of HPV in Daughter3
Yes	4.78	2.47 to 9.27	<0.001
No	1.37	0.37 to 5.16	0.64
Responsibility for Vaccine Decision4
Mother and Father	0.46	0.23 to 0.92	0.03
Other	0.31	0.10 to 0.98	0.05

¹Outcome reference group is “No/Maybe”

²Range: 3–9

³Reference group is “Don’t Know/Not Sure”

⁴Reference group is “Mother Only”

Abbreviations: HPV = human papillomavirus

Bold type indicates statistical significance p<0.05, two-tailed test

Given the established association between self-efficacy score and vaccine intention, both on its own (p<0.001) and when controlling for other variables (p<0.001), a multivariable linear regression model was constructed to determine which factors were associated with a mother’s self-efficacy score. Variables that were carried over from the simple linear regressions included the following: time in the U.S., number of sons/daughters, average household income, daughter’s place of medical care and health insurance status, perceived self-risk of cervical cancer and HPV, perceived self-exposure to HPV, worry about future HPV infection in daughter, perceived risk of HPV in daughter, HPV awareness, and vaccine responsibility. The only significant variable associated with self-efficacy was HPV awareness among mothers reporting “yes” or “no” compared to “don’t know/not sure” (regression coefficient b=0.792, p=0.001; b=0.598, p=0.04). Both of these answers compared to the “don’t know/not sure” reference group slightly increased a mother’s perceived self-efficacy score (see Table 3).

Table 3:

Multivariable Linear Regression Predicting Latina Immigrant Mother’s Self-Efficacy Scores (N=313)

	b	SE	t	p
Intercept	4.251	0.586	7.257	0.00
Months in United States	0.004	0.002	1.776	0.08
Number of Daughters	0.092	0.113	0.816	0.42
Number of Sons	−0.111	0.106	−1.042	0.30
Average Household Income (US$) Daughter’s Place of Care1	0.001	0.00	1.555	0.12
Other	−0.771	0.533	−1.448	0.15
FQHC	−0.235	0.324	−0.724	0.47
Public	0.237	0.223	1.063	0.29
HPV Awareness2
Yes	0.792	0.232	3.416	0.001
No	0.598	0.285	2.096	0.04
Daughter’s Health Insurance Status3	0.129	0.270	0.479	0.63
Responsibility for Vaccine Decision4
Mother and Father	−0.223	0.231	−0.966	0.34
Other	0.244	0.351	0.697	0.49
Perceived Self-Risk of Cervical Cancer2
Yes	0.395	0.286	1.382	0.17
No	0.093	0.246	0.378	0.71
Perceived Exposure to HPV2
Yes	−0.267	0.284	−0.940	0.35
No	0.252	0.232	1.088	0.28
Perceived Self-Risk of HPV2
Yes	0.335	0.379	0.883	0.38
No	0.101	0.224	0.450	0.65
Worry of HPV in Daughter2
Yes	0.097	0.306	0.317	0.75
No	−0.391	0.592	−0.660	0.51
Perceived Risk of HPV in Daughter2
Yes	0.397	0.220	1.801	0.07
No	0.125	0.439	0.285	0.78

¹Reference group is “Private Doctor/Clinic”

²Reference group is “Don’t Know/Not Sure’”

³Yes for health insurance status.

⁴Reference group is “Mother Only”

Abbreviations: HPV = human papillomavirus; bold type indicate statistical significance, p<0.05, 2-tailed test

DISCUSSION

Our study assessed the association between Latinx immigrant mothers’ intention to vaccinate their daughters against HPV and perceived self-efficacy. In addition, we examined factors associated with self-efficacy. Awareness of HPV risk to themselves and their daughters were significant predictors of vaccine intent, as was the mother being the sole decision maker regarding vaccination. Interestingly, participants indicating that they were not sure or did not know about HPV risks had significantly lower self-efficacy scores than both those who knew the risks and those who did not. These results are important because awareness of risks can impact health behaviors (Rosenstock, 1990). This finding supports our decision to implement an intervention aimed at increasing HPV and cervical cancer knowledge with the goal of increasing vaccine uptake. Findings from Foley and colleagues (Foley et al., 2015) that Latinx mothers were more amenable to HPV vaccines following an educational initiative also support such an approach.

Vaccine hesitancy can encompass a broad range of responses and beliefs. The Strategic Advisory Group of Experts (SAGE) Working Group defines vaccine hesitancy as a delay in acceptance despite the availability of a vaccine (MacDonald, 2015). These factors can be influenced by a variety of factors such as an individual’s perceived risk and their self-efficacy of completing the vaccination series (MacDonald, 2015).

Considering the HBM’s premise that perception and heightening of a health risk is necessary to engage in a screening or vaccination (Grace-Leitch & Shneyderman, 2016), we feel that our consideration of “don’t know/not sure” responses separately from “yes” and “no” responses was wise. Although several studies have investigated perceived risk among African American and Latinx persons (Coronado et al., 2013; Gibson et al., 2019; Luque et al., 2017), most studies either mark “don’t know/not sure” as missing or combine them with “no” responses (Hay, Orom, Kiviniemi, & Waters, 2015; Waters et al., 2016). As Waters and colleagues found, those who were unsure were more likely to be from low-income and low-education backgrounds (Waters et al., 2013), have lower screening rates, and engage in physical activity less often than “yes” or “no” respondents (Waters et al., 2016). In our study results, the differences between responses indicated that those who were unsure lacked an understanding of risks associated with HPV, reaffirming our decision to incorporate these topics in the HPV vaccine intervention that followed the baseline survey.

Multiple studies support the notion that motivation to engage in screening behaviors can be affected by individuals’ perceptions of susceptibility (Brewer et al., 2014; Brewer et al., 2007; Brewer, Weinstein, Cuite, & Herrington, 2004). Among Latina immigrants in Alabama specifically, research suggests that this population may be unsure of their cervical cancer risk (Garcés-Palacio & Scarinci, 2012). This lack of knowledge among our study participants may reduce the perceived level of risk, which could, in turn, translate into lower motivation to vaccinate their daughters.

Perceived self-efficacy, a critical component of the HBM, comes into play in our study, such that the lower our participants’ confidence in obtaining a vaccine for their daughters, the less likely they are to try (Rosenstock, 1990). This echoes findings by Tung et al., who found that women who either had never been screened for cervical cancer or had been lost to follow-up reported an inability to access or make an appointment for a screening (Tung, Lu, Smith-Gagen, & Yao, 2016). Therefore, heightening the perception of risk and also targeting self-efficacy strategies can improve vaccine intention.

Educational interventions might increase health literacy as well as broaden knowledge of HPV and cervical cancer. Among mothers in our study, the variations in HPV knowledge and intent to vaccinate mirrored similar studies that found associations between low English proficiency, low health literacy, and low socioeconomic status (Becerra, Arias, & Becerra, 2017; De Alba, Britigan, Lyden, & Johansson, 2016). Increased levels of health literacy are associated with improved health behaviors and greater self-efficacy (Guntzviller, King, Jensen, & Davis, 2017).

Interestingly, mothers who believed that the decision to vaccinate was the responsibility of both the mother and father were more hesitant to vaccinate compared to mothers who believed it was a decision they could make on their own. Similar results were found in another study assessing parental beliefs surrounding the HPV vaccine in a community in Texas; responses in these focus groups exhibited differing beliefs by gender, with men viewing the vaccine as a promotion of sexual behavior (Morales-Campos et al., 2018). It has been found that mothers are more likely to be responsible for children’s vaccinations, especially in Latino cultures (Dempsey, Abraham, Dalton, & Ruffin, 2009; Henry J. Kaiser Family Foundation, 2003; Morales-Campos et al., 2018). These results cause us to consider if interventions should be targeted to fathers as well as mothers in order to equally educate all members of a family about the HPV vaccine. However, this variable did not significantly alter a mother’s perceived self-efficacy score.

Limitations

We must note some limitations. As a cross-sectional study, information was collected from participants at one point in time. Our method of recruitment entailed assessing potential participants’ willingness to enroll, which may have introduced bias. It is possible that perceptions of HPV, cervical cancer, and mothers’ confidence in vaccinating against HPV have changed over time. However, previous qualitative work with this population indicated lower levels of susceptibility and self-efficacy (Scarinci, Litton, Garcés-Palacio, Partridge, & Castle, 2013). Thus, we made the decision to quantitatively assess these factors. Although we investigated health literacy through participants’ knowledge of HPV, further literacy could have been assessed of cervical cancer and other HPV-related health conditions, as this knowledge could change an individual’s perception of their risk. In addition, HPV knowledge and self-efficacy scores were not based on validated instruments and cannot be generalizable to other studies. We did not describe structural contributors for ethnic disparities in assessing knowledge of cervical cancer risk and the benefits of HPV vaccination. However, as this baseline survey gathered data prior to a cluster-randomized clinical trial of an HPV vaccination intervention, we developed the intervention to address barriers identified in previous studies. Finally, specific barriers that mothers perceived that may have deterred them from completing the vaccination series before this survey were not assessed. However, the intervention addressed vaccination series completion.

Implications for Practice and/or Policy

Our findings demonstrate the importance of heightening perceived risk of HPV infection and cervical cancer as well as promoting self-efficacy among Latinx mothers in order to encourage HPV vaccination among their daughters. A culturally relevant educational intervention that emphasizes the benefits and risks of the vaccine, as well as making participants aware of the accessibility of vaccines, could increase self-efficacy, intent to vaccinate, and vaccination rates. By focusing on cancer risk and HPV awareness, educational initiatives are likely to reinforce Latinx mothers’ self-efficacy, which, in turn, will promote HPV vaccination.

CONCLUSION

HPV vaccine acceptability could lead to increased uptake of the immunization and subsequent prevention of HPV-associated cancers. This study identified factors associated with HPV vaccine hesitancy in Latinx immigrant mothers in Alabama. In particular, self-efficacy is highly associated with vaccine intention when controlling for other variables. Efforts to heighten self-efficacy and determine barriers to vaccination should be targeted to improve vaccine uptake. Furthermore, efforts should be conducted to heighten the perceived risk of HPV and cervical cancer in this population.

Biographies

Author Biographies

Alexandra B. Khodadadi, MD is a physician who is currently pursuing her residency in internal medicine at Barnes Jewish Hospital in St. Louis, MO. She is committed to reducing cancer disparities, particularly among underserved populations.

Barbara Hansen, PhD is a research scientist Division of Preventive Medicine at the University of Alabama at Birmingham. Her area of expertise is in health-related stigmas, social determinants of health, and health disparities.

Young-il Kim, PhD is a senior biostatistician with expertise in statistical data analysis, particularly in the context of cancer prevention and control.

Isabel C. Scarinci, PhD, MPH. is a behavioral scientist with expertise in cancer prevention and control, particularly cervical cancer screening and HPV vaccination among underserved populations.