Hispanic mothers’ beliefs regarding HPV vaccine series completion in their adolescent daughters

Abstract

Rates of human papillomavirus (HPV) vaccine series completion among adolescent Hispanic females in Texas in 2014 (∼39%) lag behind the Healthy People 2020 goal (80%). This qualitative study identifies Hispanic mothers’ salient behavioral, normative and control beliefs regarding having their adolescent daughters complete the vaccine series. Thirty-two mothers of girls (aged 11–17) that had received at least one dose of the HPV vaccine, completed in-depth interviews. Six girls had received one dose of the HPV vaccine, 10 girls had received two doses, and 16 girls had received all three doses. The questions elicited salient: (i) experiential and instrumental attitudes (behavioral beliefs); (ii) supporters and non-supporters (normative beliefs) and (iii) facilitators and barriers (control beliefs). Directed content analysis was employed to select the most salient beliefs. Mothers: (i) expressed salient positive feelings (e.g. good, secure, happy and satisfied); (ii) believed that completing the series resulted in positive effects (e.g. protection, prevention); (iii) believed that the main supporters were themselves, their daughter’s father and doctor with some of their friends not supporting series completion and (iv) believed that vaccine affordability, information, transportation, ease of scheduling and keeping vaccination appointments and taking their daughter’s immunization card to appointments were facilitators. This study represents the first step in building theory-based framework of vaccine series completion for this population. The beliefs identified provide guidance for health care providers and intervention developers.

Introduction

The Advisory Committee on Immunization Practices recommends vaccination against human papillomavirus (HPV) between the ages of 11 and 26 [1]. HPV is associated with cervical, vulvar, vaginal, anal and oropharyngeal cancer in females [2,3]. The quadrivalent and non-avalent vaccines protect against HPV types 6 and 11 which are responsible for ∼90% of cases of genital warts [1]. They also protect against cancer-causing HPV types 16 and 18 (quadrivalent vaccine) and HPV types 16, 18, 31, 33, 45, 52 and 58 (non-avalent vaccine) [4]. In females, HPV types 16 and 18 are responsible for ∼65% of HPV-associated cancers [5–7], and HPV types 31, 33, 45, 52 and 58 are responsible for an additional 14% of cancers [1,7].

Vaccination against HPV is particularly important for Hispanic women since they suffer the highest incidence of HPV-associated cervical cancer in the US compared with other racial and ethnic groups [8]. Further, they are less likely to be screened for cervical cancer as compared with non-Hispanic white and black women [9,10]. As such, vaccinating this population against HPV is vital to reducing this health disparity.

In 2014, HPV vaccine initiation among Hispanic adolescent girls between the ages of 13 and 17 in Texas was 55.1% with vaccine series completion at only 39.3% [11,12]. The national rates for adolescent Hispanic girls for the same period were 66.3% with vaccine series completion at 48.3% [11,12]. These rates indicate that we are far from achieving the Healthy People 2020 goal of 80% HPV vaccine series initiation and completion [13]. To date, few studies have evaluated the factors influencing HPV vaccine completion in Hispanic girls. This is a significant gap given predictors of vaccine initiation and completion appear to differ [14].

Researchers have identified some factors associated with HPV vaccination in this population. Among Hispanic adolescent girls, income, health insurance coverage, age of both the mother and daughter and access to transportation have been found to be associated with HPV vaccine initiation or the intention to initiate the vaccine series in this population [15–17]. Concerns about vaccine safety, low levels of awareness and knowledge about HPV and the HPV vaccine, along with a belief that the vaccine is not effective, also predict a lower likelihood of HPV vaccine series initiation [18,19].

However, less is known about factors that predict HPV vaccine series completion in this population. Available research indicates that higher income, older adolescent and maternal age, parental knowledge of HPV and health insurance coverage predict vaccine completion [14,17,18,20–23]. Having private health insurance also increases the likelihood of series completion [24]. However, the focus on demographic predictors such as maternal age and health insurance status leaves a gap in knowledge of psychosocial factors that influence parents, particularly mothers, to have their daughter complete the vaccine series. Further, we lack a theory-based of the behavior that illustrates the psychosocial factors that interventions should address.

The Integrative Model of Behavioral Prediction (IM) [25–27] posits that behavior is likely to occur if an individual: intends to perform the behavior, possesses the necessary skills and abilities and if there are no environmental constraints to behavioral performance. Intention is predicted by the attitude toward the behavior, perceived norms, perceived control (perceived control over performing the behavior) and self-efficacy (confidence in the ability to perform the behavior). Attitudes, perceived norms, perceived control and self-efficacy are themselves predicted by behavioral, normative, and control beliefs respectively. Behavioral beliefs consist of salient experiential and instrumental attitudes (i.e. an individual’s emotional response(s) to engaging in the behavior and perceived outcomes associated with engaging in the behavior) Normative beliefs consist of injunctive and descriptive norms (i.e. behavioral supporters and non-supporters and belief about whether or not important others are performing the behavior). Perceived control is determined by control beliefs (i.e. likelihood of salient behavioral barriers and facilitators. Self-efficacy is determined by efficacy beliefs (i.e. an individual’s certainty in being able to perform the behavior under various conditions). It is critical to identify salient beliefs since IM-based interventions target these beliefs in order to influence the behavior. Beliefs are culture- and behavior-specific and their identification, through qualitative research methods, is the first step toward building a behavioral model and intervention messages [27–29].

Given the abovementioned cross-cultural and behavioral adaptability of the IM, we employed it as the guiding framework for this study. Researchers have not yet identified the beliefs related to Hispanic mothers deciding to have their adolescent daughters complete the HPV vaccine series. Therefore, the purpose of this elicitation study is to discover the most salient beliefs of Hispanic mothers about their daughters completing the HPV vaccine series. Specifically, we will discover their salient behavioral, normative and control beliefs.

Method

Participants

We conducted 32 in-depth elicitation interviews with Spanish-speaking Hispanic mothers of adolescent girls between the ages of 11 and 17 from May 2014 to January 2015. Participants were recruited from community sites including health centers and clinics in Houston, TX. Eligibility criteria included identifying as Hispanic or Latino, speaking Spanish as a primary language and having a daughter between 11 and 17-years-old, who had received at least one dose of the HPV vaccine. IM experts recommend conducting between 15 and 20 interviews with a sample composed of participants who have and have not engaged in the target behavior [30]. As such, our sample consisted of 16 mothers of girls who had not completed the dose series (6 mothers of girls who had received one dose of the HPV vaccine and 10 mothers of girls who had received two doses), and 16 mothers of girls who had completed the three dose series.

Procedure

Participants were recruited for this study using convenience sampling. Women were approached in Spanish and given a brief oral description of the study. We explained the purpose of the study, eligibility criteria, length of the interview and incentive amount. Those who met eligibility criteria and were interested in participating, were consented. Participants first completed a brief demographic survey that included items about age, country of birth, marital status and the daughter’s insurance status. Then, the interviews were conducted and audio-recorded by female research staff. The interviewers received extensive training both in the office and in the field. They practiced conducting mock interviews and then shadowed a more experienced interviewer before they began conducting interviews with study participants. Each interview took between 20 and 35 min to complete. Mothers were compensated $20 for their participation. Most participants were interviewed at the recruitment sites, but when this was not possible, interviews were conducted at the participant’s home. All procedures were approved by the Institutional Review Board at the University of Texas Health Science Center-Houston (HSC-SPH-13-0594).

Interview instrument

The interview guide consisted of open-ended questions developed after an extensive IM literature review [26,29–33]. The questions identified participants’ salient behavioral (i.e. experiential and instrumental attitudes), normative and control beliefs related to having their daughters complete the vaccine series. Four questions identified salient behavioral beliefs. Two questions identified salient experiential attitudes (i.e. positive and negative feelings about vaccinating) and two identified instrumental attitudes (i.e. positive and negative effects of vaccinating). Two questions identified salient normative beliefs (i.e. who would support vaccination and who would not support vaccination). The final two questions identified salient control beliefs (i.e. barriers and facilitators to vaccinating) (Table 1).

Table I.

Integrative Model of Behavioral Prediction (IM) belief constructs, definitions and elicitation interview questions as related to mothers’ decisions to have their daughters complete the HPV vaccine series

Construct	Definition	Interview question
Behavioral beliefs—experiential attitude	Belief that having her daughter complete the HPV vaccine series leads to certain affective outcomes	Describe the positive feelings or emotions you felt/would feel about giving your daughter the remaining doses of the HPV vaccine. Describe the negative feelings or emotions you felt/would feel giving your daughter the remaining doses of the HPV vaccine.
Behavioral beliefs—instrumental attitude	Belief that having her daughter complete the HPV vaccine series leads to certain outcomes	In your opinion, what are the positive effects of giving your daughter the remaining doses of the HPV vaccine? In your opinion, what are the negative effects of giving your daughter the remaining doses of the HPV vaccine?
Normative beliefs	Individuals the mother believes support and do not support her having her daughter complete the HPV vaccine series	Who in your life supported/would support you giving your daughter the remaining doses of the HPV vaccine? Who in your life did not support/would not support you giving your daughter the remaining doses of the HPV vaccine?
Control beliefs	Perceived barriers and facilitators to having her daughter complete the HPV vaccine series	What are some of the things that made it/would make it easier to give your daughter the remaining doses of the HPV vaccine? What are some of the things that made it/would make it harder to give your daughter the remaining doses of the HPV vaccine?

Data analysis

Interviews were transcribed verbatim by a Spanish-speaking transcriptionist. We followed Middlestadt et al.’s recommendations for collecting and analysing the interview data [34] along with other research describing elicitation studies [29–31]. Directed content analysis [35] was employed to rank and select the most salient beliefs. The primary author read the transcripts and developed a list of themes for positive and negative experiential attitudes, positive and negative instrumental attitudes, behavioral supporters and non-supporters and behavioral facilitators and barriers respectively. Themes were created by assigning concepts to key words or phrases regarding a particular belief. Similar key words and phrases were then grouped and named with a particular theme. After developing these set of themes, independent coders, including the primary author, examined the text for the pre-determined themes. This strict coding procedure was preferred in order to keep the coders on task, given that we elicited specific types of beliefs (e.g. instrumental attitudes versus beliefs about supporters). The interview transcripts were then independently coded for themes by three coders, including the primary author. Then, frequencies and percentages for the theme counts were calculated to determine the majority responses for each construct. Interrater reliability for theme coding was calculated using the kappa statistic, which exceeded 0.79 for all pairs of coders. All discrepancies between the three coders’ theme counts were examined, discussed and resolved. As recommended [29,36], we retained the most salient beliefs which we defined as, at minimum, the top 75% of salient beliefs mentioned.

Results are presented below for three salient beliefs: behavioral, normative and control beliefs. Two types of behavioral beliefs are described. They are experiential and instrumental attitudes (i.e. positive and negative feelings and positive and negative effects of the behavior). The normative beliefs described are the behavioral supporters and non-supporters. Final, the control beliefs mentioned consist of behavioral barriers and facilitators.

Results

Demographics

We present demographic characteristics of the sample in Table 2. The mean age of the sample was 41.9 (SD = 6.0) with the majority 40 years of age or older (59.4%). Most were married or living with a partner (68.8%), did not complete high school (81.3%) and all were foreign-born. Most (43.8%) had daughters between the ages of 13 and 14 with an even split between those who had daughters between 11 and 12 years of age and 15 and 17 years of age (28.1% respectively). In terms of health insurance coverage, 15.6% of the daughters lacked coverage.

Table II.

Demographic characteristics of the sample (N = 32)

	N (%)
Mother’s age (mean= 41.94, SD = 6.02)
< 40 years of age	13 (40.6)
≥ 40 years of age	19 (59.4)
Mother’s marital status
Single, never married	4 (12.5)
Married or living with partner	22 (68.8)
Separated or divorced	6 (18.7)
Mother’s education level
Less than high school completed	26 (81.3)
Completed high school	6 (18.7)
Mother’s country of birth
Mexico	18 (56.3)
El Salvador	4 (12.5)
Honduras	5 (15.6)
Guatemala	2 (6.3)
Nicaragua	1 (3.1)
Bolivia	1 (3.1)
Cuba	1 (3.1)
Daughter’s age
11–12 years of age	9 (28.1)
13–14 years of age	14 (43.8)
15–17 years of age	9 (28.1)
Daughter’s health insurance
None	5 (15.6)
Government funded/subsidized insurance	26 (81.3)
Private insurance	1 (3.1)
Daughter’s HPV vaccination status
1 dose	6 (18.8)
2 doses	10 (31.3)
3 doses	16 (50.0)

Behavioral beliefs (Table 3)

Table III.

Behavioral beliefs of the mothers regarding having their daughters complete the HPV vaccine series

Experiential attitudes
Positive feelings	Frequency	Percent	Examples of participant responses
Good	7	20.6	I felt good because, my daughter is now less likely to get [HPV] because the vaccines will prevent it.
Secure	6	17.6	As a mother, I will feel a sense of security. We vaccinate so that our children can be healthy.
Happy	6	17.6	I will feel happy because I am helping my daughter by preventing [her from getting HPV].
At ease	4	11.8	I am now at ease because when she begins to have [sexual] relations, I know that she is protected from those illnesses.
Satisfied	3	8.8	I will feel extremely satisfied to give her all three [doses of the vaccine].
Negative feelings	Frequency	Percent	Examples of participant responses
No negative feelings	19	79.2	Not one. Not one negative feeling.
Instrumental attitudes
Positive effects	Frequency	Percent	Examples of participant responses
Protection	9	25.7	I feel that because of the vaccine [doses] she is protected from the illness [HPV].
Prevention	8	22.9	More than anything it was that [the HPV vaccine] prevents cervical cancer. That is what motivated me to give [my daughter] the vaccine.
Vaccine is good	6	17.1	So that she can be well. So that she will have good health.
Daughter is/will be up-to-date with vaccinations	3	8.6	Now the vaccine series is complete. She has completed all of her [HPV] vaccine doses.
Educating daughter about maintaining good health	2	5.7	The positive effects would be that she takes control of her body and that she educates herself with respect to the illnesses that the [HPV vaccine doses] are preventing.
Negative effects	Frequency	Percent	Examples of participant responses
No negative effects	23	76.7	Well, I cannot think of any negative effect. In reality I cannot.

Experiential attitudes-positive

The five most salient positive experiential beliefs as the top 76.4% of beliefs which was closest to the 75% minimum cutoff. They included: good (20.6%), secure (17.6%), happy (17.6%), at ease (11.8%) and satisfied (8.8%). Mothers stated that they felt or would feel good, happy, at ease or satisfied because completing the series would protect their daughters from HPV and related illnesses. As one mother stated, “I felt good because now [my daughter is now more protected against the illness.”

Experiential attitudes-negative

The most salient negative experiential attitude was no negative feelings (79.2%). Some elaborated that they felt or would feel good or relieved, and not bad. For example, one mother said, “Honestly, I did not feel any negative emotion because I was thinking more about the positive things about finishing the series than the negative things.”

Instrumental attitudes-positive

We included the top 80% of beliefs. The most salient positive effects of completing the HPV vaccine series were: protection (25.7%), prevention (22.9%), vaccine is good for her health (17.1%), being up-to-date with vaccinations (8.6%) and educate daughter about maintaining good health (5.7%). Some elaborated that completing the series would protect or prevent HPV and cervical cancer and would lead to better health. One mother said, “Now my daughter is protected by the HPV vaccines. She is protected from the illness.” Others responded that it would provide an opportunity to teach daughters about how to prevent and protect themselves from illnesses.

Instrumental attitudes-negative

The most salient negative instrumental attitude was no negative effects (76.7%). Some elaborated that they did not believe that having their daughters complete the HPV vaccine series would lead to any negative effects because she did not experience any side effects from previous dose(s). As one mother stated, “I don’t think there will be any negative effects because with the first two doses everything was good. I don’t think that there will be any problem with the third one.”

Normative beliefs (Table 4)

Table IV.

Normative beliefs of the mothers regarding having their daughters complete the HPV vaccine series

Supporters	Frequency	Percent	Examples of participant responses
Daughter’s Mother (participant)	17	30.9	As her mother, I am her primary supporter. The opinions and support of others is not important to me.
Daughter’s father	16	29.1	My husband. My husband said that the decision I made [to vaccinate] was a good one and that vaccinating her was something positive.
Doctor	9	16.4	Her pediatrician. I believe [the pediatrician] supported vaccination because it is for my daughter’s own good.
Non-supporters	Frequency	Percent	Examples of participant responses
No one	22	71.0	No one, because she is my daughter and vaccinating her is my decision, only mine.
Mother’s friends	4	12.9	Many of my friends believe that vaccinating [against HPV] is bad because it will cause illnesses. They strongly believe that vaccinating will provoke sickness, but I know that it does not.

Supporters

We included the top 76.4% of beliefs. The three most salient supporters of HPV vaccine series completion were: the daughter’s mother (30.9%); the daughter’s father (29.1%); and the doctor (16.4%). The father’s desire for his daughter to enjoy good health was the main reason cited for his support. Doctors were supporters of vaccine series completion due to their role in recommending and administering the vaccine. One mother stated, “Me as her mother, and her doctor because this is something that has to do with her health.”

Non-supporters

We included the top 83.9% of responses. The two most salient categories of non-supporters were: no one (71.0%) and the mother’s friends (12.9%). Several emphasized that they could not think of anyone who would not support their decision to vaccinate because vaccination was her decision to make. One mother responded, “No one, because I am the parent and I make the decision.” Reasons for non-support from friends included: concern about side effects, lack of awareness about HPV and what the vaccine prevents and a belief that vaccination would lead to unprotected sex.

Control beliefs (Table 5)

Table V.

Control beliefs of the mothers regarding having their daughters complete the HPV vaccine series

Facilitators	Frequency	Percent	Examples of participant responses
Health insurance	14	34.2	Having health insurance, because at this moment my daughter does not have health insurance to cover the cost of the vaccine. The vaccine would be more accessible if my daughter had health insurance.
Information	6	14.6	When they gave her the vaccine doses, the clinic gave me information, brochures that explained the benefits and how the vaccine works. The doctor explained the information about how the vaccine is given and when each dose is given, very well.
Transportation	5	12.2	Truthfully, it was not difficult to vaccinate her because I had transportation.
Vaccination appointment	4	9.8	I am always aware of when the mobile van is coming to vaccinate children and once I know I make sure I take my place in line to give my daughter [the HPV vaccine]. I wait for my turn to get her the vaccine.
Cost of the vaccine	3	7.3	For me it has been easy because the mobile clinic comes and the [HPV] vaccine is free. But if I had to pay for the vaccine I do not believe that I would be able to vaccinate her.
Daughter’s vaccine card	3	7.3	Having my daughter’s vaccination card.
Barriers	Frequency	Percent	Examples of participant responses
Nothing	16	36.4	Well, honestly it was not difficult at all [to vaccinate her].
Vaccination appointment	8	18.2	The difficult thing is if the doctor cannot see her, but if the doctor can, well, then vaccinating her is easy.
Health insurance	5	11.4	My daughter not having health insurance.
Cost of the vaccine	4	9.1	The easiest thing would be if the vaccine was free. Or if it was more accessible because if I had to pay for the vaccine I do not believe that I could give it to my daughter.
Transportation	3	6.8	On one occasion we did not have anyone to take us to the clinic and so we missed her appointment. But later we made another appointment and that was when she received that final dose.

Facilitators

We included the top 85.4% of responses. The six salient facilitators included: health insurance (34.2%); vaccine information (14.6%); transportation (12.2%); vaccination appointment (9.8%); cost (7.3%) and daughter’s vaccine card (7.3%). The most salient facilitator to HPV vaccine series completion was health insurance. One mother stated, “My daughter has Medicaid. When I got her vaccinated she had Medicaid so it was easy because I did not pay for the vaccines.” Mothers who discussed vaccine information noted that they needed to be knowledgeable about the number of doses needed, the vaccination schedule and vaccine benefits. Transportation, being able to obtain a vaccination appointment, not having to pay for the vaccine doses and taking the daughter’s vaccination card to the appointment were additional facilitators to series completion.

Barriers

We included the top 81.9% of responses. We identified five salient barriers including: nothing (36.4%), vaccination appointment (18.2%), health insurance (11.4%), cost of the vaccine (9.1%) and transportation (6.8%). For example, one mother said, “Practically nothing was difficult about having her complete the series because the doctor explained everything very well and gave me information about the vaccine and how it was administered and when each dose was needed. It really was not difficult at all.”

Discussion

Behavioral beliefs

Mothers’ most salient experiential attitudes about having their daughters complete the HPV vaccine series were positive and centered on the benefits to their daughter’s health. It appears that once the vaccine series is initiated, negative feelings are no longer salient. This may be due, in part, to observations that daughters did not experience vaccine side effects. Our findings suggest that interventions should focus on reinforcing that positive feelings, specifically the ones we identified, will be felt when their daughter completes the vaccine series.

The most salient attitudes identified were positive and related to the health benefits of the vaccine. These findings are supported by existing research demonstrating that emphasizing the health benefits of the vaccine increases vaccination intention [37]. We also identified the belief that completion of the vaccine series provides mothers with the opportunity to show their daughters, the importance of maintaining good health. This novel finding provides us with an additional strategy to encourage vaccine series completion.

We did not identify salient negative effects of completing the vaccine series. The lack of salient concern about side effects is contrary to research on mothers’ concerns about vaccine uptake which has found that side effects are a concern [15,16,38]. It is possible that once a child has received a dose of the vaccine, apprehension and fears about side effects are no longer a major concern. Another explanation is that mothers downplay concerns about side effects once their daughter has received a vaccine dose. Regardless, our finding suggests that interventions for vaccine completion should focus on reinforcing the positive effects of completing the HPV vaccine series.

Normative beliefs

This is the first study to find that some mothers see themselves as the strongest supporter and advocate of vaccine series completion. Whether this view influences vaccine series completion should be investigated in future studies. This is also the first study to find that the father is a salient supporter of his daughter completing the vaccine series. Our findings emphasize the importance of focusing on increasing or reinforcing the salience of supporters of vaccine series completion. Less attention may need to be placed on decreasing the salience of those who are perceived as being unsupportive, namely the mothers’ friends since mothers in the current study did not express concern about lack of friend support.

Control beliefs

Affordability was the most salient facilitator and the second-most salient barrier of vaccination. Cost as a barrier to vaccine initiation is supported in the literature [16]. However, this is the first study to report its salience as related to HPV vaccine series completion and suggest that it is key for interventions to inform mothers about how they can get all three doses of the vaccine for their daughters through programs (e.g. vaccines for children) that cover the cost even without health insurance coverage. Knowledge about the vaccine including the number of doses in the series and the dosing schedule was a salient facilitator to vaccine series completion. As such, it is important for doctors and intervention developers to provide this information. Transportation as a salient facilitator and barrier to vaccine series completion is supported in the HPV vaccination initiation literature [39] and may be even more important for completion of the series given that transportation is needed for two additional vaccination visits. The availability, ease of scheduling, and following through with vaccination appointments to receive the remaining doses of the HPV vaccine series are salient facilitators and barriers to vaccine series completion. This is supported by research studies examining the effect of vaccine reminders on immunization rates [40] and emphasizes the importance of intervening on the provider level.

Limitations

Study findings are limited by a few factors. First, we did not include Hispanic mothers whose primary language is English and, as such, our findings cannot be generalized to these women. Also, we did not interview fathers so it is not possible to know if their beliefs are the same or different from mothers’ beliefs. In addition, our study was conducted in one geographic location, so findings may not generalize to mothers residing outside of Texas. Final, there is the possibility of interviewer bias given that data were collected via one-on-one interviews. In order to minimize this bias, we employed a structured interview guide and provided interviewers with in-depth training.

Conclusions

This study identified the salient belief structure of Hispanic mothers about having their daughters complete the HPV vaccine series. To our knowledge, this is the first study to do so. The salient beliefs we have identified can be used to develop intervention messages and guide health care providers’ conversations with Hispanic mothers about having their daughters complete the HPV vaccine series. Consequently, this study represents the first step in increasing HPV vaccination completion rates among adolescent Hispanic females using the IM.