Exploring the role of ethnic identity on the attitudes towards HPV vaccine advertising among Puerto Ricans: A qualitative analysis

Abstract

Despite the existence of guidelines recommending vaccination against the human papillomavirus (HPV) and widespread availability of the vaccine through the Vaccines for Children program, HPV vaccination rates among island Puerto Ricans are suboptimal. Advertising plays a central role in promoting HPV vaccination by increasing awareness of and knowledge about the vaccine; however, little is known about the influence of cultural factors on the impact of HPV messages delivered through the media. The aim of this qualitative study was to explore the role of ethnic identity on the attitudes towards HPV vaccine advertising among island Puerto Ricans. Five focus groups (n=23) were conducted with parents and non-vaccinated females. Our analysis found several themes that may influence attitudes towards HPV vaccine advertising among this population: physical ethnic similarity, relevance of information, and sociocultural congruence. Findings may assist in developing culturally appropriate health promotion programs and media to promote HPV vaccination among Puerto Ricans.

Introduction

Consensus guidelines recommend routine adolescent vaccination for the human papillomavirus (HPV) (1). Currently, state law in Puerto Rico (PR) mandates health insurers to cover the HPV vaccine for girls aged 11–18 years and the federally-funded Vaccines for Children program provides vaccination for eligible low-income and uninsured children. Vaccination rates among island Puerto Rican adolescent females remain suboptimal, however. As of June 2012, only 16% of Puerto Ricans girls aged 11–18 had been vaccinated with all three HPV vaccine doses (2); far from the 2020’s Healthy People goal of 80% (3). Research suggests that marketing strategies such as advertising increase awareness and knowledge of the HPV vaccine and the health benefits of vaccination (4); and perceived benefits have been associated with HPV vaccination intentions (5). For instance, direct-to-consumer or targeted advertising has been mentioned in several studies as the most common source of information about the HPV vaccine among parents (4, 6–7) and adolescents (8).

Evidence also shows that culture plays an important role in the way consumers, particularly minorities, react to and adopt health messages from advertising sources (9–10). For example, when consumers perceive racial/ethnic similarity and cultural congruence between themselves and the characteristics of the advertisement such factors enhance their liking of media source (9). In a recent study, Mueller et al. (11) found that Spanish-language television was both the most common and a highly trusted source of information about the HPV vaccine among low-income, Spanish-speaking Hispanics. Researchers have begun to investigate whether intrinsic cultural factors influence parents’ and adolescents’ attitudes towards marketing campaigns designed to promote HPV vaccination (12–14).

Despite of this research, little is known about the influence of cultural factors, such ethnic identity, on the way Puerto Ricans react to media advertising HPV vaccination. The aim of this qualitative study was to explore the role of ethnic identity on the attitudes towards HPV vaccine advertising among island Puerto Rican parents and non-vaccinated females. The results are intended to inform the development of culturally-relevant communication strategies to increase HPV vaccination among this ethnic minority group.

Methods

A convenience sampling method was used to recruit participants (15). Participants were recruited through flyers posted at the San Juan Medical Center, the largest healthcare center in PR, and by word of mouth. During April and June of 2010 three focus groups (n=16) were conducted with age-eligible females who had not received the HPV vaccine and two more groups (n=7) were conducted with parents of non-vaccinated daughters. These focus groups were part of a broader study conducted in PR that focused on HPV vaccination knowledge and attitudes among girls and parents. Discussions lasted about 90 minutes, were facilitated in Spanish by trained moderators, audio recorded, and professionally transcribed. Voluntary informed consent was obtained from all participants. Participants received $20 of compensation for their time. Study approval was obtained from the University of Puerto Rico Institutional Review Board.

A focus group guide consisting of open-ended questions to elicit participants’ knowledge, attitudes, and cultural perspectives related to HPV and the vaccine was adapted from our previous work (16). Questions addressed participants’ previous exposure to and attitudes towards HPV vaccine information sources including media. Following a question about whether or not participants had heard about the HPV vaccine, the moderator asked the following: “Where did you hear about it?” “What have you heard about the HPV vaccine?” Further probing questions on participants’ responses to media content included: “Where [media channels] did you watch the ad?” “After watching the ad, what did you think?” How does that information made you feel about the vaccine?” No advertisements were shown during the focus groups. This study reports on participants’ responses and discussions to the HPV vaccine advertising. The lead author analyzed the transcripts using the grounded theory approach (15). The research team held biweekly meetings to discuss and refine the coding list of emerging themes; discrepancies were resolved by consensus while reviewing the data. Coding was conducted using ATLAS.ti (version 6.0). Quotes were translated into English for publication purposes.

Results

Non-vaccinated participants were 16- to 26-year-old females and all reported having health insurance (Table 1). All parents (41–54 years of age) reported having some college or college degree and health insurance. Participants reported watching advertising from either local or cable television programming. Analysis of participants’ responses showed the following themes: physical ethnic similarity, relevance of information, and sociocultural congruence. These themes are discussed below; illustrative quotes are also included.

Table 1.

Characteristics of study participants

Characteristics	Adolescents and young women group (n=16)	Parents group (n=7)
Gender
Female	16	6
Male	---	1
Age, years (mean)	20.5	47.8
Highest level of education
Less than high school	4	0
High school diploma	3	0
Some college	3	1
College degree	6	6
Health insurance coverage
Any (public or private)	16	7
None	0	0

Physical ethnic similarity

Participants expressed that the ads did not appeal to them because the people who were shown on the ads did not share Puerto Rican physical characteristics. One participant indicated, “I didn’t like it [the advertisement] because their facial characteristics [of the people who were shown on the ads] are not like ours.” Another participant responded, “You watch the ads, you watch their faces; they don’t look like Puerto Ricans.” Participants also expressed that the ads were targeting Hispanics but not Puerto Ricans. One respondent said, “What I saw was an advertisement for Hispanics in the U.S., but it has never been focused for Puerto Ricans.”

Relevance of information

Participants pointed out that the information displayed in the ads was not relevant to them; some were concerned that the data presented did not relate to the Puerto Rican population. As one participant expressed, “The data is from there [the U.S.] but we don’t know what is happening here [in PR], they try to generalize it to PR.” Another participant said, “They talk about disease, about the virus but they only show examples from the U.S.” One suggested, “There are many statistics that come from there [the U.S.]…I would divide them by populations.”

Sociocultural congruence

Another theme that emerged from the discussions was the lack of social and cultural characteristics of Puerto Ricans in the ads. For example, one participant alluded to the accent of the actors, “The way they talk, the [language] accent is not of a Puerto Rican woman. I don’t feel at risk with that population and [they] are different. Maybe for the Puerto Rican in New York it may work, but not here. So it [the ad] didn’t catch my attention.” Participants also discussed differences between island Puerto Ricans and Hispanics who live in the continental U.S. including mainland Puerto Ricans. One participant said, “There are Hispanic populations that don’t necessarily behave like Puerto Ricans.” Another participant expressed, “They [mainland Puerto Ricans] behave differently… Puerto Ricans from Florida, California and New York are different. A Puerto Rican in New York [has] other lifestyles, another environment and other things. There should be a [HPV vaccination] media campaign for Puerto Ricans [in PR].”

Discussion

To our knowledge, this is the first study that assessed attitudes towards HPV vaccine advertising among both Puerto Rican parents and non-vaccinated females. This exploratory study suggests that ethnic identity plays an important role in influencing the attitudes of island Puerto Ricans towards HPV vaccination messages delivered through advertising.

Most participants mentioned the lack of physical ethnic similarities from the ads to convey the Puerto Rican population. Research has shown that peripheral approaches, the “packaging” of messages in ways likely to appeal to a targeted audience, are consistently underdeveloped in health media campaigns (10). “Surface characteristics” of the targeted audience must match health products in order to enhance their receptivity to and acceptance of messages (17). For instance, media that visually reflect the characteristics of Puerto Ricans by using spokespersons who share their physical similarities are more likely to produce a favorably response by this audience segment. This process also referred to as “felt targetedness” is driven by a consumer’s belief that he or she is the intended audience for the media because they see similarities between themselves and the people pictured in the ads (9).

Additionally, participants highlighted the importance of displaying information relevant to the Puerto Rican audience. Research shows that presenting data specific to the targeted audience increases awareness, concern, and/or perceived vulnerability to health issues by showing that it affects other people similar to the audience (10, 18). For instance, advertising showing data about the consequences of the HPV infection among the Puerto Rican population is more likely to enhance the source’s perceived relevance. Finally, the influence of the Puerto Rican sociocultural context was especially salient for participants as captured in the focus groups. Research suggests that Puerto Ricans are often reluctant to assume a broader Hispanic orientation to identify with their own national and cultural identity (19). Respondents also catalogued their mainland counterparts as a different Puerto Rican subgroup, mainly because of the well-documented differences in the lifestyles and behaviors between the groups (20).

Interpreting our results may be affected by some limitations. First, since the study was qualitative in nature, we cannot generalize the findings to all island Puerto Ricans. Second, participants’ discussions were based on recalling previous exposures to advertising. It may be that viewing other media during the focus groups would have produced different discussions than what we report here.