Cervical cancer in women is the most common human papillomavirus (HPV)-associated cancer.1 African–American women disproportionately have increased HPV-related cervical cancer incidence compared with Caucasian women.2 Gardasil-9 (Merck and Co., Kenilworth, New Jersey) is effective in combating cervical cancer,3 yet vaccination rates (60.5% for initiation; 33.4% for completion) in African–American adolescents lag behind the national recommendation of 80% similarly to the US population overall.4,5 US HPV vaccination rates in this high-risk group, regardless of gender, have yet to confer herd immunity6 which leaves many susceptible to HPV and its sequelae.
A physician’s recommendation is the preferred and effective strategy to improve HPV vaccination among African–American female adolescents.7 Factors commonly influencing a physician’s likelihood of providing a recommendation include adolescent’s age and concerns of parental resistance.8 To our knowledge, there are no studies on factors influencing African–American mothers’ likelihood of compliance to a physician’s recommendation, the primary decision makers in their adolescents’ care.9 This article identifies factors that influence African–American mothers’ likelihood of compliance with a physicians’ recommendation to vaccinate her daughter against HPV. These factors could serve as innovative and theoretically grounded intervention targets. Ultimately, this could reduce cervical cancer disparities between African–American and Caucasian women.
MATERIALS AND METHODS
Participants completed a cross-sectional survey. The “Human Papillomavirus Vaccination Survey for Black Mothers with Girls Aged 9 to 12” was developed based on prior instruments identified, validated or described in the HPV literature.10 A full description of the survey development process is described elsewhere.10 Consent was required by all participants and was approved by the University of Alabama at Birmingham’s Institutional Review Board.
Sample and Recruitment
Participants were African–American mothers Alabama residents (N = 280). They were recruited using convenience sampling from community settings (eg, schools, community organizations, churches and adolescent sports events) and online sites. Recruitment strategies included flyers at community sites and scripted e-mail correspondence to community groups/churches. Inclusion criteria were (1) mothers or legal guardians 18 years of age or older, (2) Alabama resident, (3) African–American, (4) English speaking and (5) having a 9- to 12-year-old daughter to care for/make medical decisions.
We administered the Human Papillomavirus Vaccination Survey for Black Mothers with Girls Aged 9 to 1210 in a mixed mode (ie, online and face-to-face) format. Surveys were distributed in-person. Participants who were unable to take the survey in-person received an online survey link via an e-mail from community sites. Because of initial low response rates, survey distribution was broadened statewide, resulting in collecting 280 surveys.
Study measures were parental likelihood to comply with doctor recommendation (dependent variable), parental and child sociodemographics, personal experience with HPV, most trusted information source, type of information received, knowledge of HPV, components of culture (ie, collectivism, spiritually, present-time orientation and future-time orientation) and health belief model (HBM) constructs (ie, perceived susceptibly, severity, benefits and barriers). The HBM is a theoretical model that has been successfully applied to determine why individuals engage in preventive behaviors.11 In this study, we applied this theory to understand the likelihood of African–American mothers to comply with physician’s recommendation of HPV vaccination for their daughter. Table 1 includes a description of all measures.
The original sample was 280 participants (12 online and 225 paper based). Missing data and ineligible participants resulted in 43 surveys being excluded. Final sample was 237 eligible participants. Data imputation was not used because of the high percentage of missing values. Recoding was conducted before analysis. χ2 analysis tested the association between sociodemographics and parental likelihood of compliance to the physician’s recommendation. Mann–Whitney test determined (1) HBM-based (continuous) measures to include in the logistic regression and (2) specific perceived advantages and disadvantages to include in the second logistic regression. The influence of HBM-based measures on parental likelihood to comply with a doctor’s recommendation was determined using a binary logistic regression. A second, binary logistic regression determined the association between specific perceived advantages and disadvantages and parental likelihood to comply with a doctor’s recommendation. Analyses were conducted using a 0.05 α level.
Of the 237 participants, the median age for mothers was 35 years; eldest daughters’ age was split almost equally among the ages 9, 10, 11 and 12 years. Many of mothers had a household income less than $40,000 (56.5%), a college or postgraduate degree (40.5%) and a daughter having health insurance (96.3%). About 37% of mothers had experience with HPV. While 43.5% had heard some positive information on HPV vaccine, the majority (81.4%) cited the physician as the most trusted information source (Table 2). When asked the likelihood of complying with their child’s physician to get HPV vaccine, 75.8% indicated that they were likely to comply of which 8% were vaccinated.
Chi Square Results
Of the 75% of mothers who were likely to comply with a physician’s recommendation for HPV vaccination, 44% had received positive information on the vaccine [χ2(2) = 14.897; P < 0.001], and 66% scored a doctor as the preferred health information source for their child [χ2(2) = 22.026; P < 0.001].
Mann–Whitney Test Results
Mothers with higher scores in likelihood to comply with their doctor’s recommendation also had higher perceived advantages of HPV vaccination (M = 3.73; U = −4.90; P < 0.001), perceived susceptibility of HPV (M = 2.28; U = 2.38; P = 0.009), perceived severity of HPV (M = 3.99; U = 2.75; P = 0.016) and culture: future-time orientation (M = 3.01; U = 2.13; P = 0.001). These mothers also had lower perceived disadvantages of HPV vaccination (M = 2.57) compared with those who were unlikely to comply (M = 2.91; U = 4.13; P < 0.001). There were no statistically significant differences in mother’s likelihood to comply based on culture: collectivism, culture: spirituality, culture: present-time orientation and knowledge of HPV (results not shown).
Binary Logistic Regression Models Predicting Parental Willingness
For every increase in their perceived advantages, mothers were more likely to comply with their doctor’s recommendation to get their daughter the HPV vaccine [odds ratio (OR): 2.55; P = 0.002]. Mothers who had an increase in their perceived susceptibility score were more likely to comply with a doctor’s recommendation (OR: 1.57; P = 0.047). For every increase in culture: future-time orientation, mothers were more likely to comply with the physicians’ recommendation (OR: 0.27; P = 0.001). For every increase in their perceived disadvantages score, mothers were less likely to comply with their child’s doctor recommendation (OR: 0.37; P = 0.007). No other factors were associated with mother’s likelihood (Table 3).
To determine the influence of perceived advantages and perceived disadvantages of HPV vaccination on mother’s likelihood of accepting physicians’ recommendation, a second logistic regression indicated the only significant perceived advantage was “The HPV vaccine is a good way to protect my daughter’s health.” Mothers with higher levels of agreement with this benefit were more likely to comply with their child’s doctor recommendation to get the HPV (OR: 1.76; P = 0.030). No perceived disadvantages were associated with mother’s likelihood to comply with a doctor’s recommendation (results not shown).
Several studies have identified factors influencing parental attitudes, knowledge and beliefs regarding the vaccination of their children against HPV. To our knowledge, this is the first study to identify factors influencing African–Americans mothers’ motivation to comply with a physician recommendation for HPV vaccination. Majority of mothers indicated their likelihood to comply with a physicians’ recommendation for HPV vaccination. Perceived advantages of HPV vaccination, perceived disadvantages of HPV vaccination, perceived susceptibility of HPV and culture: future-time orientation were identified as positive correlates influencing African–American mothers’ motivation to comply with a physician’s recommendation. Findings suggest that these mothers understand their daughters’ lifetime risk of HPV and the importance of HPV vaccination at early ages. However, African–American mothers are concerned about the future of their daughters’ health, so their decision-making is based on their perception of the risk the HPV vaccine on their daughter’s health.
The number of perceived advantages and perceived disadvantages of HPV vaccination, not surprisingly, was associated with greater compliance. In further exploring perceived advantages, we found the mother’s belief that the HPV vaccine is a good way to protect their daughter’s health was the most influential advantage. These mothers are most concerned about the vaccine, its health benefits and drawbacks for their daughter. Findings suggest that these mothers have a concern for their daughters’ well-being and protecting them against HPV and cervical cancer is a priority. This finding has implications for other childhood vaccines.
This study suggests that if mothers have certain information, they are more likely to comply with a doctor’s recommendation to get their daughter HPV-vaccinated. For noncompliant mothers, a stronger recommendation would include (1) etiology of HPV and their daughter’s risk, (2) link between HPV and cervical cancer later in life, (3) importance of HPV vaccination at an early age to reduce cervical cancer risk later in life and (4) possible side effects of the HPV vaccine. The limitations have been considered. First, this cross-sectional study does not allow causal inferences. Use of a convenience sample limits generalizability outside of this population and may introduce selection bias. Last, there is possibility of information and social desirability biases.
The authors thank the community organizations of Birmingham, Alabama, that assisted in the study design and allowed us to conduct this research within their organizations.
2. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus
-associated cancers—United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65:661–666.
3. Joura EA, Giuliano AR, Iversen OE, et al; Broad Spectrum HPV Vaccine Study. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372:711–723.
4. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65:850–858.
6. Brisson M, van de N, Franco EL, et al. Incremental impact of adding boys to current human papillomavirus
vaccination programs: role of herd immunity. J Infect Dis. 2011;2011:3.
7. Gargano LM, Herbert NL, Painter JE, et al. Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines. Hum Vaccin Immunother. 2013;9:2627–2633.
8. Kahn JA, Rosenthal SL, Tissot AM, et al. Factors influencing pediatricians’ intention to recommend human papillomavirus
vaccines. Ambul Pediatr. 2007;7:367–373.
9. Allen JD, de Jesus M, Mars D, et al. Decision-making about the HPV vaccine among ethnically diverse parents: implications for health communications. J Oncol. 2012;2012:401979.
10. Cunningham-Erves J, Talbott LL, O’Neal MR, et al. Development of a theory-based, sociocultural instrument to assess black maternal intentions to vaccinate their daughters aged 9 to 12 against HPV. J Cancer Educ. 2016;31:514–521.
11. Rosenstock I. Historical origins of the health belief model. Health Educ Behav. 1974;2:328–335.