Communication about Sex and HPV among Puerto Rican Mothers and Daughters

Abstract

Objective

Although opportunities to vaccinate against human papillomavirus (HPV), are available, vaccination rates in Puerto Rico remain low. Communication between parents and adolescents about sexual topics may influence decisions about HPV vaccination uptake, particularly among young women; yet few studies have addressed this issue. This qualitative study explored Puerto Rican mothers and daughters communication on sex-related topics, and HPV, including the HPV vaccine.

Design

Thirty participants, including 9 mothers and 21 daughters, participated in seven focus groups. Participants were divided into groups of mothers and daughters, and further stratified by vaccination status. Transcripts were analyzed using a modified grounded theory approach to identify emergent themes.

Results

Focus group data revealed four main themes: 1) limited parent–daughter communication about sex-related topics; 2) daughters’ discomfort discussing sex-related topics with their parents; 3) parental focus on abstinence; and, 4) limited parent–daughter communication about HPV and the HPV vaccine.

Conclusion

Although daughters in this study struggled with feelings of embarrassment, invasion of privacy, encouragement of abstinence, and the fear of parents reaction to them being sexually active prior to marriage, they also recognized the need to increase the parent-daughter communication about sex-related topics including HPV and the HPV vaccine. Educational efforts should target both daughters and parents to increase communication skills and self-efficacy and to enable them to discuss sexual health in open and nonjudgmental conversations.

Introduction

Puerto Ricans are the second largest population of Hispanic origin persons living in the United States (US) 50 states and the District of Columbia, accounting for 9.2% of the Hispanic population (USDC, 2010). Notably, cervical cancer ranks the sixth most commonly diagnosed cancer among Puerto Rican women (Figueroa, Ortiz, & Perez, 2012) despite the opportunities in primary prevention with the HPV vaccine. Recent data from the Puerto Rico Vaccination Program (July 2014) shows that in Puerto Rico (PR) only 22% of females aged 11–18 years old have completed 3 doses (PRIR, 2012), even though state law mandates health insurers to cover the HPV vaccine for that population group (Burgos, 2012).

Among older adolescents and young women, parent-daughter conversations about vaccination and HPV, an STI linked to cervical cancer, provide opportunities to talk about sexual health topics (Galagan et al., 2013; McRee et al., 2011) and may positively influence HPV vaccination uptake (Roberts et al., 2010; McRee et al., 2012). Some authors (Caal et al., 2013; Meneses et al., 2006; Guilamo-Ramos et al., 2006) highlighted the role of culture on shaping parental communication on sexual health among Hispanics, an understudied topic among Puerto Ricans. People from different cultures may have different perspectives and attitudes towards sexual socialization of their children. Mothers are recognized as the primary person responsible for the initiation of sexual socialization and education of their daughters (Kenny & Wurtele, 2013). Communication is a complex process (Guilamo-Ramos & Bouris 2008; Jaccard et al., 2002). Factors such as the content and context of communication, the frequency of parental discussion and timing is relevant at the moment of establishing effective communication strategies for parent and adolescent communication about sexual behavior. Compared with other ethnic groups (Lefkowitz 2002), research has shown mixed reports on the timing in which Latino parents discuss sexual topics, with some reports indicating that Latino parents discuss sexual topics less often than do parents of other ethnic groups (Guilamo-Ramos et al., 2006), others indicated the opposite (Reimer et al., 2012).

There may be commonly held attitudes among Hispanic mothers that sex-related behaviors may influence their communication about sex with their daughters. For example, some Hispanic parents may see pre-marital sexual activity as associated with loss purity and innocence (Romo et al., 2010); traditionally, Hispanic daughters are expected to remain virgins until marriage (Erickson, Badiane, & Singer, 2013). Additionally, according to traditional views among Hispanics, the loss of virginity may be associated with loss of self-respect, low self-esteem, and parental disapproval (Erickson, Badiane, & Singer, 2013). As a result, parental communication on sex-related topics among Hispanics may be delayed (Kenny & Wurtele, 2013), avoided, or focus on issues of abstinence only.

Findings from a national online survey indicates that, 65% of mothers reported talking with their daughters about HPV vaccine, of whom 41% said that doing so led to a conversations about sex (McRee et al., 2012). Among the general population of Hispanics, non-Hispanics whites and black mothers in the U.S. 81% reported having discussed the HPV vaccine with their daughter (McRee et al., 2011). In addition, the latter study showed that communication about HPV vaccine was more common among mothers whose daughters had been vaccinated, those who had received advice from doctors about the HPV vaccine, and those who had greater knowledge about HPV. Mother-daughter communication about HPV vaccine included comprehensive information such as: reasons for and against getting vaccinated, potential HPV vaccine benefits, usually protection against cervical cancer; less frequently, perceived disadvantages of HPV (e.g.. unknown long-term effects, painful injections) was also discussed (McRee et al., 2011). Little is known about Hispanic Puerto Rican mother-daughter communication about sex-related topics including about HPV vaccine. The purpose of this study was to explore parental and adolescent attitudes and practices related to sexual communication and discussions about HPV and the HPV vaccine in Puerto Rico.

Methods

We used a qualitative design through focus groups to accomplish the proposed objective. Focus groups can provide in-depth understanding of factors influencing health behaviors by encouraging open discussion and increasing participants’ comfort level in disclosing personal opinions (Krueger and Casey 2009). This study used a modified grounded theory approach for data collection and analysis. Grounded Theory is a set of techniques that involves the repetitive collection of information, from which conclusions are drawn to identify categories and concepts that are then linked into formal theoretical models (Corbin and Strauss 2015 & Glaser and Strauss 1967). These models consist of systematic guidelines for collecting and analyzing qualitative data to construct theories (Charmaz 2006) as well as compare themes and emerging theory to data points (Guest G et al., 2012). This type of inquiry allowed investigators to understand the socio-cultural factors surrounding Puerto Rican mothers-daughters communication about sex-related topics, HPV, and the HPV vaccine.

We recruited 30 participants for the focus groups. Inclusion criteria for participants included young women (16–26) and mothers of daughters in the same age range. Other eligibility criteria included no history of cervical cancer in mothers or daughters and daughters having knowledge of their own vaccination status as well as mothers’ knowledge of their daughter’s HPV vaccination status. Participants were all Hispanics Puerto Rican islanders.

We posted invitation flyers throughout the Puerto Rico Medical Center located in San Juan, Puerto Rico. San Juan is the capital of Puerto Rico with 381,931 residents (USDC 2010). The Puerto Rico Medical Center is part of the public healthcare system in Puerto Rico, providing primary, acute and tertiary care to the residents, primarily medically indigent population of the island. We also sent letters of invitation thorough the electronic mail system to members of the University of Puerto Rico community and to members of the Puerto Rico Cancer Control Network. Our sample consisted of interested participants that called the contact phone number and met the inclusion criteria of the study. Inclusion criteria were verified by the study coordinator during the initial contact phone call.

Prior to the focus group activity, written informed consents were obtained from all participants. Females younger than 18 years old provided their assent, and a parent-signed informed consent. To safeguard confidentiality, participants’ names was never used during discussion. The study protocol was approved by the Institutional Review Boards of the University of Puerto Rico Medical Sciences Campus, the University of Texas, School of Public Health, and the MD Anderson Cancer Center.

Data collection

We conducted seven focus groups (ranging from 3 to 8 participants), in Spanish, between April and June 2010 (n=30). Given the culturally sensitive topic of the current study on sexual-related topics, and the need to explore the perception of mothers and daughters on barriers to HPV vaccination, we conducted independent mother and daughter focus groups. A total of seven focus groups were conducted. Five focus group discussions were conducted with unvaccinated daughters or mothers with unvaccinated daughters: three groups with daughters [n=16] and two focus groups with mothers [n=6]). In order to capture information about the perception of participants about the strengths and limitations of having completed HPV vaccination, we conducted 2 additional focus groups; one with vaccinated daughters (n=5) and one with mothers of vaccinated daughters (n=3). We believe we reached saturation when we started hearing similar comments as the previous groups.

The discussion guide was adapted from a previous study that explored concerns and interests regarding HPV issues among Hispanics women in Texas (Fernandez et al. 2009). The guide included open-ended questions on knowledge, attitudes and cultural beliefs regarding HPV, the HPV vaccine and cervical cancer. Additional questions related to mother-daughter communication about sexual topics, the HPV and the HPV vaccine were included (see Table 1).

Table 1.

Interview questions from focus groups conducted in Puerto Rico with mothers and daughters about their knowledge, attitudes, beliefs and communication about the about Human Papillomavirus (HPV) vaccination.

Topic	Question
Awareness and knowledge of cervical cancer	What do you think when you hear cervical cancer? What do you know about cervical cancer? What causes cervical cancer? Who can have cervical cancer? Do you think there is a possibility your daughter may have cervical cancer in the future? Why? Why not? (Daughters’ groups only) Do you think there is a possibility you may have cervical cancer in the future? Why? Why not?
Awareness and knowledge of HPV and the HPV vaccine	Have you heard about the Human Papilloma Virus (HPV)? Where did you hear about it? Who could get HPV? (Daughters’ groups only) Do you think you could get infected with HPV? Have you heard about the HPV vaccine? What do you know about the HPV vaccine?
Attitudes towards the HPV vaccine	What do you think about vaccinating your daughter? Why? Why not? What reasons do you have for vaccinating or not vaccinating your daughter? What concerns would you have about vaccinating your daughter? What information would you need to make a decision? (Daughters’ groups only) What do you think about getting vaccinated? (Daughters’ groups only) What do you think would be the benefits of getting vaccinated? (Daughters’ groups only) What concerns would you have about getting the HPV vaccine?
Parent-Child Communication about Sexual topics	What are some of the messages that you have shared with your daughter about how they should act with boys and about sexual relations? (Daughters’ groups only) What messages do you hear the most? (Daughters’ groups only) Do you think that parents should talk to their daughters about sexual relations? What topics should they discuss with you? (Daughters’ groups only) Have you discussed sexual relations with your parents? Who initiated the conversation? How did it initiated? What are some reasons parents do not discuss sexual relationships with their daughters?
Parent-Child Communication about HPV & HPV Vaccine	What is the best way for young girls to learn about HPV? Have you talked to your daughters about HPV? (Daughters’ groups only) Have your parents talked to you about HPV? What have you talk about? (Daughters’ groups only) Do you think that parents should talk to their daughters about HPV and the HPV vaccine? What are some reasons parents do not discuss HPV and the HPV vaccine? What would help parents have discussions about HPV and the HPV vaccine with their daughters?

Before initiating the group discussion, participants reported socio-demographic information including age and marital status. Investigators also included questions to gather information about HPV and HPV vaccination status. Trained female facilitators conducted the focus groups using a series of open-ended questions going from general to specific. Sample questions included ‘Have you heard about the Human Papilloma Virus (HPV)? Where did you hear about it? Who could get HPV?’ In addition, a trained research assistant was in charge of taking detailed field notes to complement the audio data, and operating two tape recorders. Focus group discussions lasted approximately one hour. Following the discussion, participants received $20 compensation for their time along with information sheets about HPV, the HPV vaccine, and cervical cancer screening. Focus groups sessions were audio taped and transcribed verbatim. The transcripts were analyzed in Spanish and quotes were translated into English for manuscripts. Quotes were back translated to ensure accuracy.

Data analysis

The research team analyzed the transcripts using the modified grounded theory approach to identify emergent themes in the data (Krueger and Casey 2009). We used qualitative data analysis software Atlas.ti 6.1 to facilitate data manipulation and retrieval during analysis. Members of the research team independently read the transcripts, coded the data, and organized findings into categories to identify key themes. Research staff discussed conceptual differences regarding coding terminology and established a common set of codes. Findings from focus group discussions on Puerto Rican mothers and daughters’ perspectives on mother-daughter communication about sexual-related topics and HPV will be presented. A detailed description of our research methodology is presented elsewhere (Fernandez et al. 2014; Calo et al. 2015).

Results

Daughters’ ages ranged from 16 to 24 (mean of 20.4 years) and mothers’ ages ranged from 42 to 54 (mean 47.9 years). Over half of the daughters (67.0%) had some college education and 84.2% had never been married. All reported having a medical health care plan at the time of the focus group discussion. More than two-thirds (86.0%) of the mothers had a bachelors or advanced university degree and were married (75.0%).

Analysis of the focus group data revealed four themes: 1) limited parent–daughter communication about sex-related topics, 2) daughters discomfort discussing sex-related topics with their parents, 3) parental focus on abstinence, and, 4) limited parent–daughter communication about HPV and the vaccine.

Limited communication between parents and daughters about sex-related-topics

Many of the daughters expressed having very little or no communication with their parents regarding sex-related-topics. Both mothers, and daughters believed that the main barrier to discussions about sex-related-topics was feelings of embarrassment. Yet, some daughters expressed that when their mothers initiated a conversation about sex-related-topics, the mothers focused their discussions mostly on warnings about unwanted pregnancies and other consequences of sexual intercourse such as sexually transmitted infections (STIs). A mother of an unvaccinated daughter stated:

“I have been very clear about what a sexual relationship is and what the consequences are…from diseases, kids, etc. I say ‘they are your decisions, but I must tell you.’ So then you don’t have a child having a child.” Another mother from the unvaccinated group added, “Worse yet, [having] a disease for life. Those diseases that do not have a cure, ones you have to live with them for the rest of your days.”

However, some daughters believed that the main reason they do not engage in sex-related discussions with their parents is due to fear of the parent’s reactions to finding that they were sexually active (before marriage). An unvaccinated daughter shared,

“If I tell him [that I am sexually active] he is going to be upset with me, he will be disappointed in me.”

Daughters feeling uncomfortable discussing sex-related topics with their parents

Daughters also felt that it was important to share their perceptions of how uncomfortable they felt discussing sex-related topics with their parents. In general, daughters in this study believed that their sexual behavior or practices are very private in nature and discussing these topics made them uncomfortable. Several daughters expressed that they prefer their parents focus conversations about sex-related topics on STIs, instead of their sexual experiences and practices. For example, one unvaccinated daughter said, “They can talk to me about diseases, but not about sexual relations. It’s not comfortable that your parents are discussing that with you.”

Some daughters also expressed that the parental approach towards initiating conversations about sex-related topics could be a key barrier to establishing an effective conversation. For example, some daughters believed that sex-related topic conversations with their parents should be initiated using an indirect approach, such as parents discussing other people’s experiences, rather than a straight forward ‘sit down, let’s talk’ approach. An unvaccinated daughter suggested,

“I don’t think they should ask us about our personal experiences. They can ask and inform us about everything in a general way. They can ask us about our opinions, but not our experiences. And not [asking] directly. That is uncomfortable.”

Another daughter in this group discussion expressed shutting down communication with her mother after feeling ‘attacked’ by her mother’s approach. “She made me feel very ashamed of myself. That’s why I kept quiet.”

Focus on abstinence

While the majority of the mothers stated that they have focused their sex-related topic conversations on STIs, unwanted pregnancies, and birth control, other mothers believed it is important to focus their conversations on the topic of abstinence. For example, a mother of an unvaccinated daughter emphasized, “Abstinence is the best way to prevent diseases.” Surprisingly, several mothers from the unvaccinated group, although prioritizing the abstinence message, also thought it important to address the need of using protection, were their daughters to decide to become sexually active. One mother said: “Don’t do it, but if you are going to do it, protect yourself.” Consistent with these findings, the daughters that had discussed sex-related topics with their parents also reported that abstinence was the main focus of these conversations and that discussions on safe sex practices, such as condom use, were limited.

Although daughters identified abstinence as a method to prevent STIs, and a common message received from adults, they felt that many of their peers are not willing to practice abstinence. Moreover, daughters believed that safe sex education should be promoted equally as abstinence. One unvaccinated daughter shared, “I think it shouldn’t focus so much on abstinence. It is a reality that young women are sexually active so they should focus on protection and prevention, like the use of condoms, something that goes with today’s reality.”

Limited Parent-Daughter Communication about HPV and the HPV Vaccine

Focus groups revealed that despite a few exceptions, knowledge about cervical cancer, HPV, and the associations between HPV, cervical cancer and HPV vaccination was generally limited. Daughters shared more knowledge about HPV and the HPV vaccine than mothers. Daughters’ statements about knowledge of HPV included information on methods of HPV transmission and negative health outcomes. Some mothers acknowledged not discussing HPV when talking about STIs and other sex-related topics because they had no knowledge about it. One mother of a vaccinated daughter admitted, “No, I talked to her about diseases, but I talked about syphilis, gonorrhea, AIDS, but not that other one, I didn’t know that one.” While only few mothers discussed limited information about HPV, such as how is transmitted, one mother was able to discuss more detailed information. She reported to the group that she knew the HPV vaccine protects against four types of the virus and that it is given in three doses.

The few daughters that had discussed HPV-related topics with their parents stated that parents’ conversations focused mostly on preventing infection, vaccine safety, and the cost. Daughters that had not discussed HPV and the vaccine with their parents believed this could be due to parents’ lack of information about HPV and the vaccine, or to parents’ perception of it being expensive. One vaccinated daughter suggested,

“Well, maybe because they don’t know about it…or maybe the economic factor may be a possibility,… they do want to get informed, they want to make a decision about the vaccine but maybe they don’t have the money to get the vaccine.”

When discussing parent-daughter conversations about HPV and the vaccine, both mothers and daughters in the vaccinated group talked about whom the appropriate person was to make the vaccination decision. Several mothers felt that if their older daughters (late teens and early 20s) had enough information about the vaccine, they should be allowed to make the decision. One mother with a vaccinated daughter said “She was the one who made the decision. I told her ‘I would like you to [get vaccinated], but it is your decision’ and she got vaccinated.” Another mother supported her daughter getting vaccinated even against the father’s wishes:

“I told her ‘if you want to do it, then it’s ok because it’s worse for something to happen to you later and I would feel bad for not letting you [get vaccinated].’ So I authorized it and signed the papers.”

Other mothers of unvaccinated daughters felt their daughters may need to be persuaded to follow the parental wishes regarding vaccination. A mother emphasized, “They would need to be informed and convinced [to get vaccinated].” Another mother felt that since she was paying for the vaccine, she should be the one making the decision. Meanwhile some daughters felt that the decision to get vaccinated is personal, and daughters, rather than parents, should decide. One unvaccinated daughter expressed: “Because we want to prevent something happening to us; parents should understand that because it is our body; many can get tattoos without their parents knowing and yet, they can’t get a vaccine.”

Both, mothers and daughters, agreed that parent-daughter communication regarding HPV and the vaccine is important. Furthermore, a vaccinated young woman pointed out the need for parents to get accurate information about HPV and HPV vaccination in order to establish communication about the topic of HPV more effectively. Additional quotes for each section are presented in Table 2.

Table 2.

Additional quotes related to sex topics and parent-daughter communication about HPV.

Theme	Quote	Group
Limited communication between mothers and daughters about sex topics	“My parents talked [about sex], but there are things that I don’t tell them. There are things that we have to keep to ourselves.”	Unvaccinated daughter
Daughters feeling uncomfortable discussing sex topics with their parents	When asked if this is something that parents don’t talk about and that she [daughter] prefers it that way, a daughter emphasized “No. I don’t even joke about it.” “She [mother] took me to a bookstore to get books so she could sit down with me and show me very graphic pages and explain things that I already knew. That is very uncomfortable.”	Vaccinated daughter Unvaccinated daughter
Focus on abstinence	“My mother was very conservative and although she did not admonished my brothers and me [about sex], she talked to us about how things were, how sexual relationships go, but mostly she talked about abstinence; she never talked about condoms or birth control pills.”	Unvaccinated daughter
Parent-daughter communication about HPV and the HPV vaccine	“Many times parents think that they can make the decision for us when in reality… it’s a personal decision.”	Unvaccinated daughter

Discussion

This qualitative study explored the perception of mothers and daughters about communication tied to sexual-related topics, and HPV, including the HPV vaccine. In this study, parent-daughter communication in Puerto Rico about sex-related topics, is limited. This finding was consistent with other studies conducted among the Hispanic/Latino population. For example, Guilarmo-Ramos et al. (2006) reported that among Latino families, daughters and parents rarely discuss sexuality and sexual behaviors. This gap in communication about sex-related topics was related to parents’ lack of accurate knowledge, and to the child’s feelings of discomfort or embarrassment, among other reasons.

Despite the fact that daughters in this study acknowledged that parents have a responsibility to discuss sex-related topics with them, they also felt embarrassed engaging in those discussions. Similar to finding of other previous studies, daughters of this study felt uncomfortable discussing sex-related topics with their parents (Meneses et al. 2006 & Rivera et al. 2013). Our study also showed that similar to parent-daughter limited conversations about sex-related topics, there was also a gap in communication about HPV and the HPV vaccine. This finding was also consistent with other Hispanic groups in the US, Central and South America countries (Printz 2013; Romo et al. 2011; Smokowski, Rose, and Bacallao 2008) that have reported that the greatest factor influencing low levels of communication between parents and daughters was lack of knowledge about HPV and the vaccine.

While our participants discussed that lack of education about HPV was the main reason for not getting vaccinated, recent studies have proposed that low levels of HPV vaccine acceptability may be the result of misconceptions and myths that the HPV vaccine may cause sexual disinhibition (risky sexual activity) among vaccinated girls (Zimet et al. 2013). Even though sexual disinhibition was briefly mentioned in both mothers and daughters focus groups, it seems that this was not a big concern with our participants (Fernandez et al. 2014). Although encouraging that the topic of sexual disinhibition was only briefly discussed, reasons for the lack of discussion might be the age range of the daughters that were part of our focus groups.

Although daughters in our study struggle with feelings of embarrassment, invasion of privacy, encouragement of abstinence, and the fear of parents reaction to their being sexually active prior to marriage, they also recognized the need to increase parent-daughter communication about sex-related topics including HPV and the HPV vaccine. In addition, given the fact that mothers in this study had little to no knowledge about HPV, knowledge in these areas needs to be strengthened in order to assist parents and daughters in communicating about these topics and making informed decisions about vaccination. Since HPV vaccination initiation is recommended for girls 11–12 years, there is a need to start education about HPV early on. The development of school or community-based educational programs for families in PR is highly recommended.

To facilitate parent-daughter communication about sex-related topics, health promotion programs should consider the development or inclusion of tools to assist parents and daughters in communicating about sexual health. Strategies to increase skills and self-efficacy for communicating with daughters are key components in such interventions. Given that the vast majority of PR youth (11–18 years old) can benefit from Puerto Rico’s Vaccines for Children Program, which offers free vaccination until the age of 18, it is important that public advertisements describe the availability of no-cost and low cost HPV vaccinations and resources, particularly among vulnerable and underserved populations in the Island. On the other hand, the discussion regarding the options of those mothers who have private medical health plan, in which cost and access (due to lack of availability of the vaccines in their physicians office) is relevant to this subgroup. Therefore, in the context of Puerto Rico, the message regarding cost and availability should contemplate these different scenarios in order to promote opportunities to vaccinations.

Limitations

This study had several limitations. The small sample size used in our focus groups cannot be generalized to the larger population of mothers and daughters in Puerto Rico. In addition, we had low representation from mothers of vaccinated daughters. Recruitment occurred within the Metropolitan area of San Juan, Puerto Rico’s Medical Center, which most likely attracted participants with higher levels of education and higher socioeconomic status and who were more likely to have better access to HPV vaccines. Researchers also acknowledge that having participants from other socio-economic backgrounds may have enriched the study findings. Nevertheless, knowledge and communication of HPV and the vaccine was generally low to moderate among all groups. In addition, focus groups did not include parents of younger adolescents (10–13 years), the group for which vaccination initiation is recommended. It is likely that reluctance to discuss sex-related topics is even greater among parents of younger girls which may benefit from early initiation of education about HPV and HPV vaccination.

Conclusions and implications for practice

Hispanic culture influences life, activities, as well as parent and daughter communication tied to sexual-related topics including HPV and the HPV vaccine. As Calo (2015) discussed, parents do not respond favorably to health messages and campaigns that do not reflect their ethnic and cultural characteristics. Research that aims at promoting changes in health behaviors should focus on tailoring health messages so the target population identifies and relates to the information being provided. Ethnic groups do not necessarily identify with broader groupings used in health statistics and may not feel at risk. This is an important factor that may negatively impact, not only health communications with medical providers, but also parent-child communications.

Lack of information about HPV and the vaccine also appears to be an important barrier for parental initiated conversations regarding HPV. Given the discomfort felt concerning discussing sex-related topics, improved communication skills related to both sexual health and HPV related knowledge are necessary to increase these discussions, as this may impact willingness to vaccinate their children against HPV.

Lastly, given the recent recommendations for HPV male vaccination, efforts to understand factors surrounding HPV vaccination among young males within the recommended vaccination age remains an unexplored area. Therefore, there is a need to consider conducting future qualitative studies targeting parents and children from different age-gender subgroups. Specifically, future efforts should focus among young men, where a wide area of research in Puerto Rico has shown a higher burden of HPV infection as well as HPV-related cancers (Colón-López et al. 2015; Colón-López et al. 2014; Colón-López et al. 2013; Colón-López et al. 2012; Colón-López et al. 2010).

Evidence from these focus groups, along with other formative research will inform development of educational interventions. We will target both daughters and parents to increase communication skills and self-efficacy, as well to enable them to discuss sexual health in open and nonjudgmental conversations. These cues to action presented through qualitative research will help to promote discussions about HPV and the vaccine, with a direct positive impact on sexual health. As Romo (2011) discussed, improving parental-child communication about sex topics can also have a positive impact on a young woman’s confidence in talking to others about health and sex topics. This may also lead to less sexual risk-taking, seeking support for sexual health problems and better preventive health care strategies.