Our study, which focused on mothers whose daughters had been offered the HPV vaccine at a recent check up, identified 11 “themes” of reasons why mothers did or did not have their daughters vaccinated against HPV at this visit. Mothers who declined vaccination generally felt that their daughter was at low risk for HPV infection and “too young” to receive the vaccine. These mothers had significant concerns about vaccine safety, which were frequently linked to the perception that they personally lacked sufficient knowledge for making an informed decision about the vaccine or that medical establishment more broadly had inadequate information to ensure long-term efficacy and lack of adverse effects. Despite these misgivings, vaccine acceptability among mothers in the vaccine-declining group appeared to be modifiable, with many implying that they would reconsider vaccination when their daughter was older, more likely to be sexually active, and/or when more safety information was available. Mothers accepting the vaccine did so with the belief that their daughters were at high risk of acquiring HPV and that the consequences of such an infection could be severe. Though these mothers also mentioned safety concerns frequently, they were tempered by the perceived benefits to vaccination and trust in the vaccine testing and licensure process.
Findings from our study support those of multiple studies of parental HPV vaccination intention performed in a variety of settings in the United States and abroad demonstrating that issues such as perceived risk of infection, severity of disease, benefits to vaccination, and vaccine safety can all impact parental acceptability of HPV vaccination for adolescent girls (9
). Our study also identified a novel factor influencing maternal decisions about HPV vaccination that had not been previously described in the context of HPV vaccination—control over health-related behaviors. This concept appeared to have both positive and negative impacts on the decision to vaccinate among a subset of mothers. For vaccine-declining mothers, the “weight of responsibility” for making this decision, particularly in light of their significant concerns about vaccine safety, meant that it was imperative to have their daughters' input (when they were older and more mature) in the decision. In contrast, vaccine-accepting mothers found it desirable to take advantage of their current “control” over their daughter's health-related decisions, recognizing that this decision would soon be under their daughters' purview. Unlike early childhood vaccination, which is primarily under parental control, adolescent vaccine delivery requires assent from the adolescent being vaccinated. The role of adolescents' views in influencing whether HPV vaccines are received is only beginning to be studied (15
) and warrants further investigation. Linked to this concept is the issue of whether adolescents should be allowed to “self-consent” to HPV vaccination—a controversial idea that is currently under debate (36
). Finding mechanisms to improve adolescents' self efficacy for discussing the HPV vaccine with their parents may be important for increasing HPV vaccine utilization among this population. For example, having physicians provide an HPV vaccine “talking points” handout might be one way to facilitate a discussion about the vaccine between adolescents who wish to be vaccinated and their parents. Interventions such as this may be of particular use for adolescents whose parents forgo vaccination because they are embarrassed or reluctant to discuss the vaccine, but who want their daughter to have a role in the decision to be vaccinated.
Our study also demonstrated that many more mothers who declined HPV vaccination had not seen their child's regular provider when compared to mothers accepting the vaccine. Though none of the vaccine-declining mothers in our study mentioned decreased familiarity with their child's provider as a reason for their decision, our results may point to an important, though perhaps subconscious, aspect of HPV vaccination that should be considered when designing outreach and intervention strategies to promote use of this vaccine by adolescents. Numerous studies demonstrate that provider recommendation is a critical factor for vaccination (10
), and it is conceivable that some of the mothers declining vaccination in our study would have had a different opinion about the vaccine had they been able to discuss it with a provider with whom they had more experience and trust. Future studies should investigate how provider familiarity impacts parental views of the HPV vaccine and adolescent HPV vaccine administration.
Mothers who declined vaccination in our study seemed to have modifiable views about the vaccine as many were open to the idea of having their daughters vaccinated in the future, either when they judged them more likely to be sexually active, or when additional safety and efficacy data were available. This suggests that these mothers were not inherently against HPV vaccination per se, but rather that the perceived balance of “risks” to benefits of HPV vaccination was unfavorable. Several studies demonstrate that HPV infection occurs soon after sexual initiation (38
) and that adolescents and young adults are at highest risk of being infected (39
). Because parents frequently misjudge their child's level of sexual activity (40
), adopting a “later would be better” attitude about HPV vaccination could have detrimental health effects by failing to prevent HPV infection among sexually active adolescents. This lack of urgency about the need for HPV vaccination has been documented in other studies (27
) and may be an important target for public educational campaigns in the future. For example, some parents may find messages that center on the high prevalence of HPV among adolescents and the high risk of HPV infection with even just one sexual partner compelling, especially when these risks are presented in direct comparison to the low risk of adverse health effects from HPV vaccination.
A limitation of our study was that the maternal sample was derived from patients seen for preventive care visits only; it did not include mothers whose daughters were offered the HPV vaccine at a problem-related outpatient visit or mothers who are unable to, or choose not to, access preventive care services. In addition, we primarily relied on spontaneous maternal responses to an open-ended question to identify reasons underlying decisions about HPV vaccination (as opposed to querying mothers directly about specific reasons). This approach was chosen so as to minimize interviewer-imposed bias in responses, but it is possible that some mothers had additional reasons underlying their decision that they did not feel comfortable discussing with the interviewer. In addition, questions were asked of mothers days or weeks after their daughter's medical visit. The reasons for mothers' decisions identified by our study may not be completely reflective of their decision-making process at the actual time of vaccine consideration. An additional potential limitation was the lack of diversity in our sample: All participants had access to health care and our sample was highly educated. Racial/ethnic information about the participants was unknown. However, the aim of qualitative studies is not to generate results generalizable to a population, but rather to achieve the intended goal of the studyd—in this case to develop a deeper understanding of the reasons behind maternal decisions about HPV vaccination. Finally, although we had originally intended to explore both parents' views on HPV vaccination for their daughters, only two fathers were identified through our recruitment process. Previous studies indicate that mothers are the primary parent responsible for taking their children to the doctor. It is therefore not surprising that the majority of study participants identified by our study as “the person who accompanied their daughter to her recent check up” were mothers. However, given the controversy related to the sexual transmissibility of HPV, it is conceivable that fathers may play a more active role in decisions about HPV vaccination than for other vaccines. Further exploration of the role of fathers in this process, and their potential to serve as advocates for, or opponents of, HPV vaccination is needed.