Abstract
Background
Human papillomavirus (HPV) is the most common sexually transmitted disease in the US and the primary cause of cervical cancer. Vietnamese American women have the highest incidence rates of cervical cancer but one of the lowest HPV vaccination rates. Parental knowledge is an important predictor of HPV vaccination; however, little is known about HPV knowledge in the Vietnamese American community. We aimed to describe the HPV knowledge of Vietnamese mothers in Houston, Texas and their intention to vaccinate their daughters.
Methods
We conducted face-to-face interviews with Vietnamese mothers who had daughters aged 9–26 years. We collected data on demographics, acculturation, HPV knowledge, and vaccination intention. Knowledge scores (0–5) were calculated using 5 knowledge questions. We used logistic regression to identify predictors of HPV knowledge.
Results
Participants had low levels of acculturation by report of reading (31%) and writing (23%) English well. Less than 50% of participants (n=47) had heard of HPV, and among these, the mean HPV knowledge score was 4. Although only 1 in 3 had discussed HPV with their medical provider, nearly 86% of participants who had not heard of HPV would vaccinate their daughter if their doctor had recommended it. Good written English skills and belief that the HPV vaccine was not expensive were predictors of HPV awareness.
Conclusions
HPV awareness is low among less acculturated Vietnamese mothers in Houston. Future educational efforts about the role of HPV vaccine in preventing cervical cancer should be made in their language when targeting parents of a high risk Vietnamese population.
Keywords: Human papillomavirus, Vietnamese, Knowledge, Awareness
Introduction
The human papillomavirus (HPV) is the most common sexually transmitted disease and is responsible for most cervical cancers [1], despite available effective vaccines [2]. Though the Centers for Disease Control and Prevention has approved the Advisory Committee on Immunization Practices’ recommendation that all girls aged 11–12 years be vaccinated for HPV [3, 4], only about 40% of Asian-American girls 13–17 have received one or more doses of the HPV vaccine [5]. In Houston, Texas, where the Vietnamese population is the largest Asian American subgroup and is steadily increasing [6], providers have reported overall vaccination rates of approximately 25% and 36% for girls age 9–12 and 13–17 years, respectively [7].
The incidence of cervical cancer among Vietnamese American women is the highest in the US, 16.8 per 100,000 [8], but screening is among the lowest in the country, with only 60–70% of Vietnamese American women receiving a Pap test over three years [9–11]. Though studies have shown that education level [12], English proficiency [13], and income [14] are associated with Pap test knowledge, there is a lack of literature about HPV vaccine knowledge within the Vietnamese American community. Previous studies have shown missed opportunities for physicians to educate their patients about HPV and cervical cancer. Low rates of physician recommendation for the HPV vaccine have also been reported, especially among younger children [15, 16]. Physician recommendation has been shown to be a predictor of HPV vaccine acceptance [17] and has been shown to be an important predictor of Asian mothers’ likelihood to have their daughters vaccinated [18].
With new recommendations for a broader HPV vaccination campaign [3] and evidence that HPV is responsible for more cancers than originally thought [19], community education is important in reducing the incidence of HPV and cervical cancer. Targeted interventions for young women at risk and their families are needed, but gaps in HPV knowledge must first be identified. To that end, we aimed to study HPV knowledge among Vietnamese mothers in Houston, Texas.
Methods
Study Population
This study was approved by the University of Houston Committee for the Protection of Human Subjects. We used a purposive sample method during a 2-month period in 2011. We approached Vietnamese women at the largest Vietnamese shopping center in the greater Houston, Texas area for possible participation in the study. We chose this recruitment method in order to access hard to reach populations such as Vietnamese-American women with limited English proficiency because traditional sampling methods (e.g., random digit dialing) are not consistently feasible [20, 21]. A participant was eligible for the study if she: 1) provided informed consent; 2) self-identified herself as Vietnamese; and 3) had a daughter aged 9–26 years old. Two trained female research staff, bicultural and bilingual in Vietnamese and English, conducted face-to-face interviews using an English or Vietnamese survey instrument, depending on the interviewee’s language preference. Participants received a $10 gift card to compensate for their time.
Survey Instrument
Questionnaires were translated from English into Vietnamese by native Vietnamese speaking research staff. This instrument was piloted with a lay audience and reviewed and approved by a Project Advisory Committee composed of 10 members, including physicians, health educators, nurses, and Vietnamese community organization leaders, and other health professionals with cancer expertise. The instrument included demographic information such as participant’s age, educational level, length of residence in the US, acculturation level, and insurance. Questions that assessed knowledge about HPV and cervical cancer were derived from previous survey tools [10, 22, 23].
Outcome Measures
We asked all participants whether they had heard of HPV infection. Of those who indicated that they had heard of HPV, we asked them if their doctor had ever talked about HPV and whether their daughter had received the HPV vaccine in the past. Also, among participants who had heard of HPV, we asked a series of specific questions to assess their knowledge. A knowledge score was calculated using the respondent’s answers to five HPV knowledge questions. These questions assessed knowledge about: (i) causative relationship of HPV and cervical cancer, (ii) transmission route, (iii) symptoms, (iv) prevention, and (v) behavioral risk. One point was assigned for each question that was answered correctly with a total possible score between 0 and 5. We then averaged the knowledge scores of all respondents.
Statistical Methods
We compared characteristics between patients who were screened and were not screened using Pearson’s chi-square tests. We examined the relationships of the main outcomes with each independent variable using simple logistic regression. Potential predictors with a p-value less than 0.20 in univariate analyses were entered into multiple logistic regression models for each outcome. The final model was selected using a backward elimination method where variables with a p≤0.05 remained in the model. We used SAS software, version 9.13 (SAS Institute, Cary, North Carolina) and the Statistical Package for the Social Sciences, version 19 (IBM, Armonk, New York) for statistical analyses.
Results
Participant Characteristics
Characteristics of our study population are shown on Table 1. All 95 women had been born in Vietnam and described their level of acculturation to be low despite having lived in the US for an average of 18 years. Nearly half of participants had heard of HPV infection, and in general, they were more acculturated than the women who had not heard of HPV. Compared to those who had not heard of HPV, mothers who had heard of the virus had higher levels of education, insurance, and proficiency in writing English (P<0.05). Mothers who had heard of HPV also tended to be more proficient at understanding and speaking English (P<0.10). Among those who had heard of HPV, only 31.9% (n=15) had talked with their doctor about HPV; however, 86% reported that they would vaccinate their daughter if their doctor recommended it.
Table 1.
Characteristics of participants by HPV awareness
| Total Sample (n=95) | Heard of HPV (n=47) | Had Not Heard of HPV (n=48) | |
|---|---|---|---|
| Characteristic | n (%) | n (%) | n (%) |
| Age, years (mean ± SD) | 48.9 ± 7.3 | 47.8 ±7.2 | 50.1 ± 7.4 |
| Born in Vietnam | 95 (100) | ||
| Time living in US, years (mean ± SD) | 18.2 ± 10.9 | 19.1 ± 11.0 | 17.3 ± 10.8 |
| Understands spoken English | |||
| Not at all to somewhat well | 63 (66.3) | 27 (57.5) | 36 (75.0) |
| Well to very well | 32 (33.7) | 20 (42.6) | 12 (25.0) |
| Speaks English | |||
| Not at all to somewhat well | 67 (70.5) | 29 (61.7) | 38 (79.2) |
| Well to very well | 28 (29.5) | 18 (38.3) | 10 (20.8) |
| Reads English | |||
| Not at all to somewhat well | 66 (69.5) | 29 (61.7) | 37 (77.1) |
| Well to very well | 29 (30.5) | 18 (38.3) | 11 (22.9) |
| Writes English* | |||
| Not at all to somewhat well | 73 (76.8) | 30 (63.8) | 43 (89.6) |
| Well to very well | 22 (23.2) | 17 (36.2) | 5 (10.4) |
| Education* | |||
| Grade ≤ 12 | 58 (61.1) | 23 (48.9) | 35 (72.9) |
| Some college | 14 (14.7) | 8 (17.0) | 6 (12.5) |
| College degree and above | 23 (24.2) | 16 (34.0) | 7 (14.6) |
| Job status† | |||
| Employed (full/part-time) | 60 (63.2) | 31 (66.0) | 29 (60.4) |
| Unemployed | 9 (9.5) | 4 (8.5) | 5 (10.4) |
| Retired/student/homemaker | 23 (24.2) | 11 (23.4) | 12 (25.0) |
| Other | 2 (2.1) | 0 (0) | 2 (4.2) |
| Religion | |||
| Catholic | 42 (44.2) | 18 (38.3) | 24 (50.0) |
| Buddhist | 48 (50.5) | 24 (51.1) | 24 (50.0) |
| Other | 5 (5.3) | 5 (10.6) | |
| Relationship status | |||
| Single (not dating/not living together) | 3 (3.2) | 2 (4.3) | 1 (2.1) |
| Living w/ significant other | 85 (89.5) | 43 (91.5) | 42 (87.5) |
| Separated/divorced | 7 (7.4) | 2 (4.3) | 5 (10.4) |
| Type insurance*† | |||
| Insured | 62 (65.3) | 36 (76.6) | 26 (54.2) |
| Uninsured | 28 (29.5) | 9 (19.2) | 19 (39.6) |
| Income† | |||
| < $20,000 | 27 (28.4) | 14 (29.8) | 13 (27.1) |
| $20,000 to $40,000 | 25 (26.3) | 13 (27.7) | 12 (25.0) |
| > $40,000 | 35 (36.8) | 15 (31.9) | 20 (41.7) |
p < 0.05 when comparing participants who had heard of HPV and those who had not
Job status: n < 95 because of missing data (n=1)
Type insurance: n < 95 because responses of “Don’t Know” (n=4) and “Refused” (n=1) were omitted Income: n <95 because responses of “Don’t Know” (n=6) and “Refused” (n=2) were omitted
HPV Knowledge
Knowledge was further assessed for participants who indicated that they had heard of HPV infection (Table 2). Most of the respondents answered the knowledge questions correctly, with an average score of 4 (± 0.86) out of 5 for this group. However, only 45% of respondents knew that individuals with HPV infection may not have any symptoms, therefore making it difficult to know that they are infected.
Table 2.
Knowledge among 47 participants who had heard of HPV
| Response, n (%) | |
| HPV Knowledge | Correct1 |
| People infected with HPV are at higher risk for cervical cancer | 43 (91.5) |
| Women get infected with HPV, and pass the virus to partners. | 43 (91.5) |
| People infected with HPV usually can tell they have it | 21 (44.7) |
| Vaccination against HPV will help reduce the risk of developing cervical cancer | 43 (91.5) |
| Adolescents are likely to get infected with HPV once they start having sex | 38 (80.9) |
| HPV Knowledge Score2 | Mean ± SD |
| 4.00 ± 0.86 | |
Abbreviations: SD, standard deviation
The correct response for all questions is “True,” except for “People infected with HPV usually can tell they have it.”
Knowledge scores were calculated by assigning 1 to all correct responses to HPV knowledge questions. Each of the 47 respondents who answered the HPV knowledge questions was assigned a score ranging from 0–5.
Predictors of HPV Awareness
Univariate analyses showed that insured participants and those who could write English were significantly more likely to have heard of HPV (Table 3). In the multiple logistic regression analysis, both English writing proficiency and belief that the HPV vaccine was affordable were significantly associated with awareness of HPV infection.
Table 3.
Predictors of HPV awareness
| Characteristic | Total (n=47) |
Simple LR | Multiple LR1 | ||
|---|---|---|---|---|---|
| n (%) | OR (95%CI) | p-value | OR (95%CI) | p-value | |
| Education | |||||
| ≤ HS | 23 (48.9) | 0.36 (0.15–0.84) | 0.02 | ||
| > HS | 24 (51.0) | Ref | -- | ||
| Job status | |||||
| Employed | 31 (51.7) | 1.2 (0.51–2.9) | 0.66 | ||
| Unemployed | 4 (44.4) | Ref | |||
| Religion | |||||
| Catholic | 18 (42.9) | Ref | -- | ||
| Buddhist | 24 (50.0) | 1.3 (0.58–3.1) | 0.50 | ||
| Relationship status | |||||
| Single/separated/widowed | 4 (8.6) | Ref | -- | ||
| Living together | 43 (50.6) | 1.5 (0.40–5.8) | 0.53 | ||
| Type insurance | |||||
| Insured | 36 (58.1) | 2.9 (1.1–7.5) | 0.02 | 3.3 (1.0–10.9) | 0.05 |
| Uninsured | 9 (32.1) | Ref | -- | Ref | -- |
| Income | |||||
| <20,000 | 14 (51.9) | 1.4 (0.52–3.9) | 0.48 | ||
| 20,000–40,000 | 13 (52.0) | 1.4 (0.52–4.0) | 0.48 | ||
| >40,000 | 15 (42.9) | Ref | -- | ||
| Understand English | |||||
| Not at all to somewhat well | 27 (42.9) | Ref | -- | ||
| Well to very well | 20 (62.5) | 2.2 (0.93–5.3) | 0.07 | ||
| Speak English | |||||
| Not at all to somewhat well | 29 (43.3) | Ref | -- | ||
| Well to very well | 18 (64.3) | 2.4 (0.95–5.9) | 0.06 | ||
| Read English | |||||
| Not at all to somewhat well | 29 (43.9) | Ref | |||
| Well to very well | 18 (62.1) | 2.1 (0.85–5.1) | 0.11 | ||
| Write English | |||||
| Not at all to somewhat well | 30 (41.1) | Ref | -- | Ref | -- |
| Well to very well | 17 (77.3) | 4.9 (1.6–14.6) | 0.00 | 7.7 (2.0–30.1) | 0.00 |
| Easy to understand provider | |||||
| Agree | 41 (48.8) | 0.38 (0.07–2.1) | 0.26 | ||
| Disagree | 5 (71.4) | Ref | -- | ||
| HPV vaccine too expensive | |||||
| Agree | 26 (58.3) | 0.56 (0.24–1.3) | 0.18 | 0.11 (0.02–0.78) | 0.03 |
| Disagree | 21 (44.1) | Ref | -- | Ref | -- |
Only variables that had a p-value ≤ 0.25 were included in the multiple logistic regression; Missing ORs and p-values due to unstable estimates because of small sample sizes
Discussion
This is the first, in-depth study of HPV knowledge and awareness among Vietnamese American mothers and was conducted in the 3rd largest Vietnamese population in the US. We found that HPV awareness was low among Vietnamese mothers who had daughters, and written English proficiency predicted HPV awareness. Among participants who had heard of HPV infection, we found that more than 55% incorrectly reported that HPV patients usually have symptoms indicating infection.
Our finding of low HPV awareness among Vietnamese mothers in Houston (49.5%) was consistent with other studies that found between 19% and 66% of Asian American women had previously heard of HPV [18, 24–27] At the time of our study, our results represented the largest study of Vietnamese American women whose risk of cervical cancer is the highest among all US women [8].
We found that most participants who were aware of HPV incorrectly thought that HPV symptoms were obvious, a finding consistent with another study of Asian parents [28]. Studies conducted in other populations also found that most women had low knowledge of HPV symptoms [29, 30]. Future educational efforts should be made to inform at risk group of the relatively silent symptoms of HPV infection and the importance of screening and vaccination in asymptomatic individuals.
Our finding that English writing ability was associated with HPV awareness also has important implications for future educational campaigns, highlighting the need for culturally and linguistically competent educational materials and tools. Vietnamese American mothers who lack written English proficiency may represent a special group of women at risk, and more community-based research will be needed to elucidate optimal educational and behavioral strategies to improve awareness and prevention. Indeed, previous research has found English proficiency to be a predictor of HPV vaccination among immigrant Asian women [31].
We found that participants who were aware of HPV were significantly more likely to be insured. This finding has important implications for the Vietnamese American community. One study found that 30% of the Vietnamese population in Houston and its surrounding areas were uninsured in 2004 [32] compared to 11% of whites in 2010 [33]. Studies have shown that having insurance is associated with intent to receive the HPV vaccine in Asian [31] and other [34] populations.
Our study had several limitations. The study participants represented a convenience sample of Vietnamese American women and thus our results may not be generalizable to other populations. There may have been inherent biases in our sampling technique; however, we targeted patrons from various socioeconomic statuses at the largest Vietnamese shopping center at multiple times of the day over a 2-month period. Additionally, although our study focused on HPV awareness and knowledge, we did not explore the health literacy of the study participants. Future research should further study this and validate participants’ HPV knowledge and ability to discern HPV from other viruses, such as human immunodeficiency virus, or hepatitis B or C infections. Finally, our knowledge score represents an initial step in describing participants’ HPV knowledge, and this score will require future validation in a larger study.
Our findings will allow us to take the next step in developing tailored community-based educational programs for Vietnamese American mothers. This will improve their awareness of HPV infection and help them understand the importance of HPV vaccination for their daughters who may be at high risk of cervical cancer. Additional studies are needed to confirm the effect of culturally competent educational programs and the impact medical providers who care for Vietnamese American mothers and their daughters have on improving HPV vaccination rates.
Acknowledgements
The authors thank Hong Zhang, MS, for assistance with data analysis, and Donna Huang for administrative assistance.
Funding: Dr. Yi received funding for this research from the Cancer Prevention Research Institute of Texas (CPRIT) Health’s Promotion, Public Education, and Outreach Programs Award PP100016. Dr. Hwang is supported by the National Cancer Institute of the National Institutes of Health (NIH) under Award Number K07CA132955. The content is solely the responsibility of the authors and does not necessarily represent the official views of the CPRIT or NIH.
References
- 1.Munoz N, Bosch FX, de Sanjose S, Herrero R, Castellsague X, Shah KV, Snijders PJ, Meijer CJ. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med. 2003;348:518–527. doi: 10.1056/NEJMoa021641. [DOI] [PubMed] [Google Scholar]
- 2.Scarinci IC, Garcia FA, Kobetz E, Partridge EE, Brandt HM, Bell MC, Dignan M, Ma GX, Daye JL, Castle PE. Cervical cancer prevention: new tools and old barriers. Cancer. 2010;116:2531–2542. doi: 10.1002/cncr.25065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.CDC. [cited 2011 Nov 1];2011 Available from: http://www.cdc.gov/media/releases/2011/t1025_hpv_12yroldvaccine.html.
- 4.Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Morbidity & Mortality Weekly Report. 2007;56:1–24. [PubMed] [Google Scholar]
- 5.Dorell CG, Yankey D, Santibanez TA, Markowitz LE. Human papillomavirus vaccination series initiation and completion, 2008–2009. Pediatrics. 2011;128:830–839. doi: 10.1542/peds.2011-0950. [DOI] [PubMed] [Google Scholar]
- 6.U.S. Census Bureau. One Race: Asian. Mapping Census 2000: The Geography of U.S. Diversity. 2000 Available from: http://www.census.gov/population/cen2000/atlas/censr01-108.pdf.
- 7.McCave EL. Influential factors in HPV vaccination uptake among providers in four states. J Community Health. 2010;35:645–652. doi: 10.1007/s10900-010-9255-4. [DOI] [PubMed] [Google Scholar]
- 8.Miller BA, Chu KC, Hankey BF, Ries LA. Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U.S. Cancer Causes Control. 2008;19:227–256. doi: 10.1007/s10552-007-9088-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Ponce N, Gatchell M, Brown ER. Cancer screening rates among Asian ethnic groups. Los Angeles: UCLA Center for Health Policy Research; 2003. [Google Scholar]
- 10.Taylor VM, Yasui Y, Burke N, Nguyen T, Acorda E, Thai H, Qu P, Jackson JC. Pap testing adherence among Vietnamese American women. Cancer Epidemiol Biomarkers Prev. 2004;13:613–619. [PubMed] [Google Scholar]
- 11.Taylor VM, Nguyen TT, Jackson JC, McPhee SJ. Cervical cancer control research in Vietnamese American communities. Cancer Epidemiol Biomarkers Prev. 2008;17:2924–2930. doi: 10.1158/1055-9965.EPI-08-0386. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.McPhee SJ, Bird JA, Davis T, Ha NT, Jenkins CN, Le B. Barriers to breast and cervical cancer screening among Vietnamese-American women. Am J Prev Med. 1997;13:205–213. [PubMed] [Google Scholar]
- 13.Nguyen TT, McPhee SJ, Nguyen T, Lam T, Mock J. Predictors of cervical Pap smear screening awareness, intention, and receipt among Vietnamese-American women. Am J Prev Med. 2002;23:207–214. doi: 10.1016/s0749-3797(02)00499-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Schulmeister L, Lifsey DS. Cervical cancer screening knowledge, behaviors, and beliefs of Vietnamese women. Oncol Nurs Forum. 1999;26:879–887. [PubMed] [Google Scholar]
- 15.Raley JC, Followwill KA, Zimet GD, Ault KA. Gynecologists' attitudes regarding human papilloma virus vaccination: a survey of Fellows of the American College of Obstetricians and Gynecologists. Infect Dis Obstet Gynecol. 2004;12:127–133. doi: 10.1080/10647440400020661. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Vadaparampil ST, Kahn JA, Salmon D, Lee JH, Quinn GP, Roetzheim R, Bruder K, Malo TL, Proveaux T, Zhao X, Halsey N, Giuliano AR. Missed clinical opportunities: Provider recommendations for HPV vaccination for 11–12 year old girls are limited: Vaccine. 2011 Sep 14; doi: 10.1016/j.vaccine.2011.09.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Zimet GD, Mays RM, Winston Y, Kee R, Dickes J, Su L. Acceptability of human papillomavirus immunization. J Womens Health Gend Based Med. 2000;9:47–50. doi: 10.1089/152460900318957. [DOI] [PubMed] [Google Scholar]
- 18.Chow SN, Soon R, Park JS, Pancharoen C, Qiao YL, Basu P, Ngan HY. Knowledge, attitudes, and communication around human papillomavirus (HPV) vaccination amongst urban Asian mothers and physicians. Vaccine. 2010;28:3809–3817. doi: 10.1016/j.vaccine.2010.03.027. [DOI] [PubMed] [Google Scholar]
- 19.Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, Sibug-Saber M, Cozen W, Liu L, Lynch CF, Wentzensen N, Jordan RC, Altekruse S, Anderson WF, Rosenberg PS, Gillison ML. Human Papillomavirus and Rising Oropharyngeal Cancer Incidence in the United States. Journal of Clinical Oncology. 2011;3:3. doi: 10.1200/JCO.2011.36.4596. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Muhib FB, Lin LS, Stueve A, Miller RL, Ford WL, Johnson WD, Smith PJ. A venue-based method for sampling hard-to-reach populations. Public Health Rep. 2001;1:216–222. doi: 10.1093/phr/116.S1.216. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Miller KW, Wilder LB, Stillman FA, Becker DM. The feasibility of a street-intercept survey method in an African-American community. Am J Public Health. 1997;87:655–658. doi: 10.2105/ajph.87.4.655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Lam TK, McPhee SJ, Mock J, Wong C, Doan HT, Nguyen T, Lai KQ, Ha-Iaconis T, Luong TN. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. J Gen Intern Med. 2003;18:516–524. doi: 10.1046/j.1525-1497.2003.21043.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Grant D, Kravitz-Wirtz N, Breen N, Tiro JA, Tsui J. One in four California adolescent girls have had human papillomavirus vaccination. Policy Brief UCLA Cent Health Policy Res. 2009;3:1–6. [PubMed] [Google Scholar]
- 24.Hsu YY, Cheng YM, Hsu KF, Fetzer SJ, Chou CY. Knowledge and beliefs about cervical cancer and human papillomavirus among Taiwanese undergraduate women. Oncol Nurs Forum. 2011;38:E297–E304. doi: 10.1188/11.ONF.E297-E304. [DOI] [PubMed] [Google Scholar]
- 25.Wong LP. Knowledge and attitudes about HPV infection, HPV vaccination, and cervical cancer among rural southeast Asian women. Int J Behav Med. 2011;18:105–111. doi: 10.1007/s12529-010-9104-y. [DOI] [PubMed] [Google Scholar]
- 26.Bastani R, Glenn BA, Tsui J, Chang LC, Marchand EJ, Taylor VM, Singhal R. Understanding suboptimal human papillomavirus vaccine uptake among ethnic minority girls. Cancer Epidemiol Biomarkers Prev. 2011;20:1463–1472. doi: 10.1158/1055-9965.EPI-11-0267. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Gor BJ, Chilton JA, Camingue PT, Hajek RA. Young Asian Americans’ knowledge and perceptions of cervical cancer and the human papillomavirus. Journal of Immigrant and Minority Health. 2011;13:81–86. doi: 10.1007/s10903-010-9343-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Jaspers L, Budiningsih S, Wolterbeek R, Henderson FC, Peters AA. Parental acceptance of human papillomavirus (HPV) vaccination in Indonesia: a cross-sectional study. Vaccine. 2011;29:7785–7793. doi: 10.1016/j.vaccine.2011.07.107. [DOI] [PubMed] [Google Scholar]
- 29.Pitts M, Clarke T. Human papillomavirus infections and risks of cervical cancer: what do women know? Health Educ Res. 2002;17:706–714. doi: 10.1093/her/17.6.706. [DOI] [PubMed] [Google Scholar]
- 30.Blodt S, Holmberg C, Muller-Nordhorn J, Rieckmann N. Human Papillomavirus awareness, knowledge and vaccine acceptance: A survey among 18– 25 year old male and female vocational school students in Berlin, Germany. Eur J Public Health. 2011;23:23. doi: 10.1093/eurpub/ckr188. [DOI] [PubMed] [Google Scholar]
- 31.Nguyen GT, Chen B, Chan M. Pap Testing, Awareness, and Acceptability of a Human Papillomavirus (HPV) Vaccine Among Chinese American Women. J Immigr Minor Health. 2012;24:24. doi: 10.1007/s10903-012-9607-5. [DOI] [PubMed] [Google Scholar]
- 32.Hoang T, Gor B, Hernandez M, Liang J, Esparza A, Detry M, Yi J, Jones L. Asian American Health Needs Assessment, 2006 Community Report. Houston (TX): Center for Research on Minority Health, The University of Texas MD. Anderson Cancer Center; 2006. Nov. [Google Scholar]
- 33.Behavioral Risk Factor Surveillance System. 2010 Health Access: No Health Insurance Area: Houston MSA. [March 20, 2012];2010 Available from: http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm. [Google Scholar]
- 34.Liddon NC, Hood JE, Leichliter JS. Intent to receive HPV vaccine and reasons for not vaccinating among unvaccinated adolescent and young women: findings from the 2006– 2008 National Survey of Family Growth. Vaccine. 2012;30:2676–2682. doi: 10.1016/j.vaccine.2012.02.007. [DOI] [PubMed] [Google Scholar]