ABSTRACT
Objectives
To analyze the presence, framing, and cultural accessibility of HPV vaccination messaging related to oropharyngeal squamous cell carcinoma (OPSCC) prevention among health institutions serving Middle Eastern and North African (MENA) populations in the United States.
Materials and Methods
Cross‐sectional content analysis of publicly available HPV vaccination materials from 37 MENA‐serving institutions (24 health systems, eight public health departments, five community‐based organizations) across eight U.S. metropolitan counties selected using 2020 U.S. Census‐derived MENA population estimates. Reporting followed SRQR guidelines. Primary outcomes included presence of head and neck cancer language, HPV‐16 mention, cervical cancer‐dominant framing, Arabic/Farsi/Turkish language access, and cultural tailoring.
Results
Twenty‐six of 37 institutions (70.3%) provided HPV vaccination content. Among these, 14 (53.8%) included head and neck cancer language and only 4 (15.4%) mentioned HPV‐16. A cervical cancer‐dominant framework was present in 13 (50.0%). Eight institutions (30.8%) offered Arabic, Farsi, or Turkish language access. Cultural tailoring was present in 12 (46.2%). No community‐based organizations provided HPV vaccination content.
Conclusion
HPV vaccination messaging among MENA‐serving institutions inadequately reflects OPSCC epidemiology. Head and neck cancer language, HPV‐16 mention, language access, and cultural tailoring remain inconsistent. Otolaryngologists are well positioned to advocate for cancer‐inclusive, culturally responsive HPV prevention messaging.
Level of Evidence
4.
Keywords: health disparities, HPV vaccination, human papillomavirus, MENA populations, oropharyngeal squamous cell carcinoma
1. Introduction
While the general population associates head and neck cancer with tobacco smoking and alcohol use, human papillomavirus (HPV)‐positive oropharyngeal squamous cell carcinoma (OPSCC) is rising steadily in the United States and is becoming one of the most rapidly increasing malignancies in the country. Multiple studies have reported HPV‐positive OPSCC as the most common HPV‐related malignancy nationwide, surpassing cervical cancer [1, 2]. Most oropharyngeal cancers related to HPV are due to the high‐risk strain, HPV‐16, and these HPV‐positive OPSCC define a biologically distinct disease entity [3, 4]. Compared to HPV‐negative OPSCC, HPV‐positive head and neck malignancies have a better prognosis. Despite this fact, the growing incidence of HPV‐positive OPSCC reflects a preventable public health burden.
Since its introduction in the early 2000s, HPV vaccination has been proven to be a highly effective method of immunization against high‐risk strains of HPV, including HPV‐16 [5]. Currently, national guidelines recommend immunization at 11 or 12 years old [6]. While these are the recommendations, compliance with these guidelines is suboptimal and varies greatly across demographic and cultural populations. Multiple factors influence the decision to vaccinate against HPV, from access to the way HPV prevention campaigns are framed and delivered [7, 8].
HPV vaccine utilization is significantly lower among MENA individuals. Foreign‐born adults have an HPV vaccination initiation rate of 9.5%, compared to 19.7% among U.S.‐born adults, with significantly lower adjusted odds of initiation even after controlling for demographic and healthcare access factors [9]. Among Arab American parents, 63.5% of immigrant Arab mothers reported their children were unvaccinated, citing lack of awareness and absence of a provider recommendation as primary barriers [10]. Providers noted that culturally tailored educational materials in Arabic would be highly useful, underscoring the critical need for linguistically and culturally appropriate HPV messaging to reduce prevention inequities in MENA communities [11].
Historically, most public health campaigns for HPV immunization have focused on cervical cancer prevention [12, 13]. Men are disproportionately impacted by HPV‐positive OPSCC, and so campaigns that focus on cervical cancer do not fully encompass the current disease burden or apparent association across various populations [13]. Specifically, to communicate with Middle Eastern and North African (MENA) populations in the United States, culturally and linguistically tailored information is vital. This demographic is a growing population in the United States that is understudied in scientific literature [14, 15]. Their relationship with preventative health communications may be influenced by language access, cultural practices, and trust in healthcare institutions [14, 15]. Currently, it remains unclear whether institutional information regarding HPV vaccination incorporates current head and neck cancer epidemiology or culturally sensitive communication strategies.
1.1. Objectives
Our study seeks to strategically analyze institutional HPV immunization materials to identify the presence, framing, and cultural accessibility of HPV‐related OPSCC prevention content among MENA‐serving institutions.
2. Methods
2.1. Study Design
We conducted a cross‐sectional content analysis of publicly available HPV vaccination health communication materials. The analytic approach aimed to describe how institutions frame HPV vaccination in institutional messaging, specifically focusing on content relevant to head and neck cancer prevention and otolaryngology.
2.2. Reporting Guideline
This study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR). No clinical trial registration was required as the study analyzed only publicly available data and did not involve human subjects.
2.3. Setting and Participants
Institutions selected for this study were health systems, public health departments, and community‐based organizations that serve Middle Eastern and North African (MENA) populations from multiple regions of the United States. The selection process involved choosing institutions based on geographic location in counties that have established MENA populations as identified using 2020 U.S. Census‐derived estimates. Additionally, we chose counties to represent both regions with the largest absolute number of MENA residents and regions with high proportions of MENA population concentrations. Thus, we were able to capture various community contexts.
Included counties consisted of major metropolitan areas and included Wayne County, Michigan; Los Angeles County, California; Kings County, New York; Cook County, Illinois; Fairfax County, Virginia; Passaic County, New Jersey; Santa Clara County, California; and Hennepin County, Minnesota. Our use of this geographic sampling design enhanced the relevance and generalizability of our findings to various institutional and regional settings that serve MENA populations.
2.4. Data Sources
To identify publicly accessible web pages for each eligible institution, we completed systematic web‐based searches using standardized search terms including “HPV vaccine”, “human papillomavirus”, “vaccination”, and “immunization”. Search terms were entered into institutional websites and publicly searchable search engines. All pages containing HPV vaccination‐related information intended for patient or public education were considered eligible for inclusion. If an institution had no HPV vaccination content on its website, it was documented as such (i.e., did not reference HPV vaccination).
2.5. Main Outcome Measures
Each eligible webpage was reviewed and coded using a structured abstraction framework developed prior to data collection. The primary outcomes of interest were the presence and framing of cancer prevention messaging related to HPV vaccination. Specifically, webpages were coded for inclusion of head and neck cancer–specific language, defined as explicit reference to oropharyngeal, tonsillar, or throat cancer in the context of HPV infection or vaccination. Explicit mention of HPV‐16, the predominant oncogenic subtype associated with HPV‐related oropharyngeal squamous cell carcinoma, was also recorded.
Cancer framing was further categorized based on whether messaging used a cervical cancer–dominant framework. This was defined as primary or exclusive emphasis on cervical cancer prevention with minimal or no mention of head and neck cancers. Secondary outcomes included availability of translated HPV vaccination content in Arabic, Farsi, or Turkish, reflecting common languages spoken within MENA communities. Language access was defined as the presence of translation functionality or standalone translated materials addressing HPV vaccination.
The effectiveness of cultural tailoring was also evaluated as a secondary outcome. Tailoring was defined as the inclusion of culturally relevant images, culturally tailored messaging, or other graphic/textual elements intended to be culturally specific (e.g., depictions of diverse patients).
Independent variables examined in this evaluation include organization type (health system, public health department, or community‐based organization) and the presence of language access.
2.6. Data Abstraction and Quality Control
Coding was completed using predetermined definitions to improve consistency and reproducibility. Each institution was evaluated as a single unit of analysis. Coding reflected whether the presence of each outcome existed within the publicly accessible HPV vaccination materials from each institution. If there were multiple webpages at a single institution, all applicable webpages were reviewed, and outcomes were coded as existing if they were found on any one of the reviewed webpages.
2.7. Statistical Analysis
Descriptive analyses were performed. All outcomes were summarized using count and proportion summaries, both overall and by organization type. Additional descriptive analyses were completed among the subset of institutions that referenced HPV vaccination to examine variability in cancer framing, language access, and cultural tailoring conditionally upon vaccine‐related messaging. Inference through statistical testing was not performed as the purpose of this study was not to test hypotheses or make population‐level inferences.
2.8. Ethical Considerations
This study analyzed only publicly available data and did not involve human subjects or access of private data. Therefore, it was determined to be non‐human subjects research and thus did not require Institutional Review Board (IRB) approval.
3. Results
3.1. Study Sample Characteristics
Of the 37 institutions serving MENA populations in the study, 24 were health systems, 8 were public health departments, and 5 were community‐based organizations. Altogether, 26 (70.3%) of the institutions were found to have publicly available information about the HPV vaccine, and 11 (29.7%) did not report on the HPV vaccine (Table 1).
TABLE 1.
Characteristics of HPV vaccination messaging among MENA‐serving institutions.
| Characteristic | N (%) overall | N (% among HPV vaccine–mentioning systems; N = 26) |
|---|---|---|
| HPV vaccine mentioned | 26 (70.3%) | — |
| Head and neck cancer mentioned | 14, 37.8% | 14, 53.8% |
| Arabic/Farsi/Turkish access | 8, 21.6% | 8, 30.8% |
| Cervical cancer framework | 13, 35.1% | 13, 50.0% |
| Cultural tailoring | 12, 32.4% | 12, 46.2% |
| HPV‐16 strain mentioned | 4, 10.8% | 4, 15.4% |
Institutions were drawn from eight metropolitan counties with established MENA populations, selected a priori using 2020 U.S. Census‐derived estimates (Table 2), capturing both high absolute and high proportional MENA concentrations.
TABLE 2.
Geographic distribution of counties included and estimated MENA population characteristics.
| Metro area | County | State | Estimated MENA population (Count) | Estimated MENA population (% of County) |
|---|---|---|---|---|
| Detroit Metro | Wayne County | MI | ~140,000 | ~7.8% |
| Los Angeles Metro | Los Angeles County | CA | ~228,000+ | ~2.3% |
| New York City Metro | Kings County (Brooklyn) | NY | ~52,000 | ~1.9% |
| Chicago Metro | Cook County | IL | ~78,000 | ~1.5% |
| Washington, DC Metro | Fairfax County | VA | ~55,000 | ~4.8% |
| New York City Metro | Passaic County | NJ | ~35,000 | ~6.7% |
| San Francisco Bay Area | Santa Clara County | CA | ~32,000 | ~1.7% |
| Minneapolis–St. Paul Metro | Hennepin County | MN | ~12,000 | ~0.9% |
3.2. HPV Vaccination Messaging by Organization Type
HPV vaccination information was available for 20 (83.3%) of 24 health system sites and six of eight (75.0%) public health department sites; none (0%) of community‐based organization websites included HPV vaccination information (Table 3). Among institutions providing HPV content, health systems accounted for 20 of 26 (76.9%) and public health departments for 6 of 26 (23.1%).
TABLE 3.
HPV vaccination messaging characteristics by organization type among MENA‐serving institutions.
| Organization type | HPV vaccine mentioned | Head and neck cancer mentioned | HPV‐16 mentioned | Cervical cancer framework | Arabic/Farsi/Turkish access | Cultural tailoring |
|---|---|---|---|---|---|---|
| Health systems (overall; N = 24) | 20/24 (83.3%) | 11/24 (45.8%) | 3/24 (12.5%) | 11/24 (45.8%) | 7/24 (29.2%) | 11/24 (45.8%) |
| Health systems (among those mentioning HPV vaccination; N = 20) | — | 11/20 (55.0%) | 3/20 (15.0%) | 11/20 (55.0%) | 7/20 (35.0%) | 11/20 (55.0%) |
| Community organizations (overall; N = 5) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) |
| Community organizations (among those mentioning HPV vaccination; N = 0) | — | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) | 0/5 (0%) |
| Public health departments (overall; N = 8) | 6/8 (75.0%) | 3/8 (37.5%) | 1/8 (12.5%) | 2/8 (25.0%) | 1/8 (12.5%) | 1/8 (12.5%) |
| Public health departments (among those mentioning HPV vaccination; N = 6) | — | 3/6 (50.0%) | 1/6 (16.7%) | 2/6 (33.3%) | 1/6 (16.7%) | 1/6 (16.7%) |
3.3. Head and Neck Cancer Prevention Language
Among the 20 health systems that mentioned HPV vaccination, 11 (55.0%) included language specific to preventing head and neck cancer, referencing oropharyngeal, tonsillar, or throat cancer related to HPV infection or vaccination. The remaining nine health systems (45.0%) mentioned HPV vaccination without reference to head and neck cancer (Table 3).
Among the six public health departments that mentioned HPV vaccination, three (50.0%) included language specific to preventing head and neck cancer, whereas three (50.0%) did not. In total, among all institutions that mentioned HPV vaccination, 14 of 26 (53.8%) included language for head and neck cancer prevention (Table 3).
3.4. Cancer Framing and HPV‐16 Mention
Eleven of 20 Health Systems (55.0%) referred to HPV vaccination within a cervical cancer–dominant framework. In these cases, messaging emphasized the prevention of cervical cancer as the primary rationale for vaccination with little or no mention of head and neck cancers. Similarly, a cervical‐cancer‐dominant framework existed in two of six (33.3%) public health departments where HPV vaccination was mentioned (Table 3).
Institutional references to HPV‐16, the viral subtype most strongly linked to head and neck cancers caused by HPV, were rare. 3 of 20 (15.0%) health systems that referenced HPV vaccination specifically mentioned HPV‐16. One of six (16.7%) public health departments that referenced HPV vaccines mentioned HPV‐16. Overall, 4 of 26 (15.4%) references to HPV‐16 were found (Table 3).
3.5. Language Access
Availability of HPV vaccine content in Arabic, Farsi, or Turkish varied depending on organizational type. Seven of 20 (35.0%) health systems that referenced HPV vaccines provided language access in at least one of these languages. Only one of six (16.7%) public health departments providing HPV vaccine content provided some kind of language access (Table 3).
Overall, 8 of 26 (30.8%) institutions referencing HPV vaccine content provided Arabic, Farsi, or Turkish language access (Table 1).
3.6. Cultural Tailoring
Cultural tailoring, defined as the use of culturally diverse imagery or context for messaging, was found in 11 of 20 (55.0%) health systems referencing HPV vaccination while cultural tailoring was found in only one of six (16.7%) public health departments referencing HPV vaccination (Table 3).
Overall, 12 of 26 (46.2%) institutions referencing HPV vaccine content demonstrated evidence of cultural tailoring (Table 1).
4. Discussion
4.1. Synopsis of Key Findings
Despite HPV immunization being referenced by the majority of MENA‐serving health systems and public health departments, explicit head and neck cancer prevention language was present in only half of institutions, and HPV‐16 was rarely mentioned. A substantial proportion of institutional materials centered on cervical cancer prevention. This is noteworthy given that HPV‐positive OPSCC is now the most common HPV‐related cancer in the United States [2]. Our findings suggest that institutional communications have not kept pace with the evolving epidemiology. This does not undermine the importance of cervical cancer awareness—but a cervical‐cancer‐exclusive focus fails to capture the full spectrum of HPV‐related malignancy.
4.2. Comparisons to Other Studies
Previously, it has been shown that HPV vaccine acceptability is higher among men when vaccination is framed in the context of cancer prevention rather than genital wart prevention alone [7].
4.3. Clinical Applicability and Generalisability
Across institutions, there was heterogeneity regarding language accessibility and cultural tailoring. Less than one‐third of institutions offered content regarding HPV vaccination in Arabic, Farsi, or Turkish. MENA communities are very diverse linguistically, and thus, limited resources in these languages may decrease engagement with preventive health resources. A few institutions did provide imagery or messaging that was culturally tailored; however, these attempts were inconsistent and even more rare among public health departments. To improve trust and preventive health measures, culturally responsive communication is vital [16], and thus, intentional outreach strategies in diverse communities are of the utmost importance.
Community‐based organizations also demonstrated a lack of content related to HPV, highlighting another missed opportunity to raise awareness among MENA populations. Organizations within the community are often viewed as trusted intermediaries among immigrant and minority populations, and thus must not be overlooked when spreading preventive health information [17]. Future partnerships may be considered with these organizations to increase awareness regarding HPV vaccination to prevent OPSCC.
4.4. Limitations and Strengths
This study has several limitations. Web‐based materials do not capture in‐clinic counseling or in‐person community outreach. Content analysis identified the presence of messaging but not its effectiveness or impact on vaccination behavior. A strength of this study is the systematic, predetermined coding framework applied across a diverse sample of institution types and geographic regions.
Regardless of this study's limitations, the findings emphasize a vital gap between current HPV epidemiology and institutional preventive information. With the continued rise of HPV‐related OPSCC [1, 2], it is essential to continue to advocate for explicit language regarding head and neck cancer prevention when disseminating HPV vaccination materials. By doing so, the disease burden and public messaging will be more closely aligned. Otolaryngologists routinely care for patients with HPV‐related OPSCC, and thus are uniquely poised to champion broader, cancer‐inclusive preventive messaging.
Future studies should examine whether integrating OPSCC‐specific language and improved language accessibility into HPV vaccination materials increases vaccine engagement. Stronger partnerships between health systems, public health departments, and community‐based organizations are needed to expand the reach and cultural responsiveness of HPV prevention.
In conclusion, HPV vaccination is widely referenced among MENA‐serving institutions, but OPSCC‐specific messaging and language accessibility remain limited. Aligning institutional communications with current HPV epidemiology is essential for strengthening primary prevention in underserved communities.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
Artificial intelligence language model tools (Perplexity AI; Claude, Anthropic) were used to assist with editing and manuscript preparation. All AI‐assisted content was reviewed, edited, and verified by the authors, who take full responsibility for the accuracy and integrity of the manuscript.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.