Human Papillomavirus Vaccine Acceptance (HPV-VA) and Vaccine Uptake (HPV-VU): Assessing the Impact of Theory, Culture, and Trusted Sources of Information in a Hispanic Community

"...findings have implications for designing trusted, theory-based, and culturally sensitive health communications and interventions to promote vaccines in minority underrepresented communities."



Human papillomavirus (HPV) is the most common sexually transmitted infection and is associated with many types of cancers that disproportionately impact Hispanics. An HPV vaccine is available for individuals ages 9-45 that can prevent up to 90% of HPV-associated cancers. This study examines the impact of theory-based factors (i.e., the Health Belief Model, or HBM), culture-based factors that may be unique to Hispanics of Mexican-American origin (e.g., language, household size, religiosity, stigma), and trusted sources of information on HPV vaccine acceptance (HPV-VA) and HPV vaccine uptake (HPV-VU) in a predominately Hispanic community.



A cross-sectional study design with an online questionnaire was used to collect data from a community sample of 602 adults between the ages 18-65 residing in a United States (US)/Mexico border city, El Paso, Texas. Theory-based factors, culture-based factors, and trusted sources of information were examined as predictors of HPV-VA and HPV-VU.



Approximately 65% of the sample reported they have not received the HPV vaccine. Of those who reported having received the HPV vaccine, only 6.8% reported having received two doses, and 9.5% reported having received three doses. Participants reported they have been recommended the HPV vaccine from the following informational sources: a healthcare practitioner (60.1%), a community health clinic (16.4%), the internet (14.6%), family/friends (14.3%), television (9.8%), social media (9.6%), a school nurse (6.6%), community health worker or promotor(a) de salud (4.2%), a government website) (3.5%), the World Health Organization (WHO) (3.5%), a pharmacist (2.8%), a pharmacy (2.2%), the radio (1.8%), the newspaper (1.3%), and "other" (5.1%).



Linear regression models revealed that HPV-VA was associated with household size, primary language, engagement in organisational religious activities (e.g., attending church), health-related community stigma, government trust, and the HBM-theory-based factors of: perceived benefits, perceived harm, and perceived severity. Logistic regression analyses revealed that HPV-VU was associated with household size, engagement in non-organisational religious activities (e.g., engaging in private prayer), HPV trusted sources of information, and perceived safety.



To look more closely at the associations related to culture:

• Individuals were more likely to accept the HPV vaccine if Spanish was the primary language at home.
• Individuals residing in larger households were more likely to accept the HPV vaccine.
• Individuals were more likely to accept the HPV vaccine if they reported higher frequency of attending church or other religious meetings; they were more likely to get the HPV vaccine if they engaged in private prayer, meditation, or Bible study.
• Individuals are less likely to accept the HPV vaccine if they experience higher levels of stigma from their community.

The strongest association in the study was between family-held beliefs that vaccines cause autism and one's own belief that vaccines cause autism. This finding may be related to fraudulent research by Andrew Wakefield that (wrongly) suggested that the meales, mumps, and rubella (MMR) vaccine caused autism. The researchers suggest that family-focused health communications and interventions that effectively dispel myths and misperceptions about the HPV vaccine may be warranted.



Another notable finding is that there was not a significant association observed between knowledge about HPV and HPV-VA. Although counterintuitive, this finding is consistent with prior studies that also reported no effect. Thus: "When designing interventions researchers should have primary goals of increasing other factors aside from knowledge (e.g., increasing perceived benefits and safety of the HPV vaccine) to have a greater impact on HPV-VA and HPV-VU."



That said, the study highlights how "trust in the government and various sources of information might influence HPV-VA and HPV-VU. Trust is a critical factor in healthcare and the formation and maintenance of productive relationships between patients and providers. Medical mistrust can prevent individuals from seeking healthcare and limit compliance with medical advice or treatment. Specific to HPV-VA and HPV-VU, provider recommendation has been established as one of the most important variables in the decision to vaccinate....Trust in a provider, coupled with strong recommendation behavior, should result in higher vaccination rates and reduced cancer incidence over time."



Suggestions for future work include:

• Practice: "Utilizing both theory-based and exploratory cultural data could offer opportunities for future education models that help increase vaccine uptake and acceptance within a specific ethnicity/race (e.g., Hispanic). In addition,...the incorporation of data based on exploratory cultural constructs should be considered when developing interventions for HPV-VU (i.e., increasing household size, non-organizational activity) and HPV-VA (i.e., primary language, increasing household size, organizational activity). Educational interventions tailored for communities can help address HPV-VU and HPV-VA."
• Policy: "Utilizing the findings of this study to create interventions grounded in theory-based frameworks allows for opportunities for advocacy at both local and state levels. A variety of platforms (i.e., social media, print) can be used that are cost-efficient and simple to execute."
• Research
  • "Although theory-based factors have demonstrated generalizability, other factors should continue to be explored (i.e., local norms) to fully understand the depth and breadth of vaccine uptake and acceptance in vulnerable populations (i.e., Hispanics)."
  • "In vulnerable communities, additional research is needed that incorporates other factors and considerations including understanding discrimination and its roles in health behaviors, how the individual feels about their community (i.e., job availability, crime, parks, air population), and its role in health behaviors, and mental health."
  • "[T]here is a critical need for identifying numerous culture-based factors associated with vaccine acceptance in Hispanics to inform the development of culturally tailored interventions for promoting the HPV vaccine." For example, "it is critical to investigate how Hispanic parents' perceptions influence vaccine rates in their children."

Thus, the hypothesis that theory-based factors would be associated with HPV-VA and HPV-VU was supported. Several other findings highlight the need for health professionals and practitioners to tailor interventions to Hispanics, embracing cultural and language preferences. "Integrating the cultural values of familism, personalism, collectivism, and marianismo/machismo into social and health interventions will help increase the likelihood of participation and meaningful engagement..."