Exploring Mother-daughter Communication and Social Media Influence on HPV Vaccine Refusal for Daughters Aged 9-17 Years in a Cross-sectional Survey of 11,728 Mothers in China

"Understanding mothers' vaccine refusal is pivotal to facilitating the successful implementation of the national HPV vaccination program..."

In line with the socio-ecological model, mother-daughter communication related to human papillomavirus (HPV) vaccination is a group of interpersonal factors that may influence decisions about daughters' vaccination. Such interactions may occur both online (through the internet and social media) and offline. This study investigated the influences of mother-daughter communication and social media on mothers' HPV vaccine refusal for their daughters aged 9-17 in Shenzhen, China, a city in the Guangdong province where the pilot scheme under the national HPV vaccination programme is implemented.

A cross-sectional online survey among 11,728 mothers was implemented between July and October 2023. In case the participant has more than one eligible daughter aged 9-17 years, she referred to the one whose birthday is closest to the survey date (the "index daughter") when answering questions. Multi-level logistic regression models were fitted.

Over half of the participants reported being the main decision-makers for their index daughters' HPV vaccination (53.5%). Less than 30% of the participants were sometimes/always exposed to testimonials given by parents about daughters' HPV vaccination (29.1%), negative information about HPV vaccines (27.7%), and other vaccine incidents (25.8%) on common social media platforms. About half of them were sometimes/always exposed to information encouraging parents to vaccinate their daughters against HPV through such channels (49.1%). About half of them sometimes/always consider the veracity of information specific to HPV vaccines in the past month (50.5%).

Among the index daughters of all participants, 18.9% had received the HPV vaccination. The level of HPV vaccine refusal was 43.2% for the index daughters and 36.9% for the participants themselves.

In multivariate analysis, more openness in the mother-daughter communication (adjusted odds ratio (AOR): 0.99, 95% confidence interval (CI): 0.98, 0.99), perceived more positive outcomes of mother-daughter communication (AOR: 0.77, 95% CI: 0.75, 0.79), higher frequency of exposure to testimonials about daughters' HPV vaccination (AOR: 0.81, 95% CI: 0.78, 0.85) and information encouraging parents to vaccinate their daughters against HPV on social media (AOR: 0.76, 95% CI: 0.73, 0.79), and thoughtful consideration of the veracity of the information specific to HPV vaccines (AOR: 0.80, 95% CI: 0.77, 0.83) were associated with lower vaccine refusal. Also, in line with previous studies, higher socioeconomic status (higher education, higher income, and full-time employment) was associated with lower HPV vaccine refusal in this study. (Mothers with higher socioeconomic status usually have better health literacy.)

Mothers who were not the main decision-makers of daughters' HPV vaccination (AOR: 1.28 to 1.46), negative outcome expectancies of mother-daughter communication (i.e., expectations about the outcomes of conversation having negative effects) (AOR: 1.06, 95% CI: 1.04, 1.08), and mothers' HPV vaccine refusal (AOR: 2.81, 95% CI: 2.58, 3.06) were associated with higher vaccine refusal for their daughters.

This has some practical implications for developing health promotion programmes for mothers:

1. Openness in mother-daughter communication was associated with lower HPV vaccine refusal for daughters in this study. Mothers with an open communication style are more likely to communicate their opinions, concerns, and expectations for a health-related behaviour (i.e., taking up HPV vaccination) directly to their children. This study suggested that promoting open communication within the family may improve children's healthy behaviours and well-being.
2. About 30% of the mothers perceived some negative outcomes of mother-daughter communication about HPV vaccination (i.e., the daughter will get confused or argue with them), and such negative outcome expectancies were associated with higher vaccine refusal. Testimonials of mothers about the positive outcomes of parent-daughter communication about HPV vaccination and learning skills to address daughters' concerns and emotional responses to HPV vaccination may be useful to modify outcome expectancies.
3. Health authorities should consider using their official social media accounts to disseminate health promotion messages related to HPV vaccination. These official social media channels were regarded as credible information sources among Chinese people. In line with previous studies, thoughtful consideration of the veracity of information specific to HPV vaccination played an important role in reducing vaccine refusal.
4. Subgroup analyses suggested that mothers having daughters aged 9-12 years had higher HPV vaccine refusal than those with daughters aged 13-17 years. The pilot scheme under the national HPV vaccination programme provides free HPV vaccines to girls aged 13 years or above in Shenzhen. Mothers with daughters under 13 might prefer waiting until their daughters become eligible for the pilot scheme. The government should consider expanding the pilot scheme to cover girls aged 9-12 years to maximise its public health benefits.

Thus, the level of mothers' HPV vaccine refusal for their daughters was high in China. One reason: Unlike many developed nations, China has not incorporated HPV vaccination into its childhood vaccination scheme. As a result, mothers in China may perceive HPV vaccination as optional and less imperative for their daughters. Openness and outcome expectancies of mother-daughter communication and information exposure on social media were considered key determinants of HPV vaccine refusal for daughters in this study. Future vaccination programmes and policymakers may consider these interpersonal factors to address and mitigate HPV vaccine refusal effectively.