Health disparities have been identified in the incidence of cervical cancer.² Incidence is greater in Hispanic and African American women compared to non-Hispanic white women.⁶ Research suggests that being an ethnic minority is associated with high-risk HPV prevalence.⁷ In order to alleviate racial and ethnic health disparities, it is necessary to understand the most effective way to promote vaccine uptake in individuals from diverse cultures.

Models of health behavior (i.e., Health Belief Model⁸) suggest that individuals' beliefs about the riskiness and severity of a health threat, as well as their expectations about the pros and cons of taking action, influence health-protective behavior. For example, the belief that receiving the HPV vaccine will effectively reduce the likelihood of contracting HPV has been associated with willingness to receive the vaccine. Also, the perceived likelihood of getting cervical cancer and perceived negative side effects of the vaccine are also significant predictors of vaccine uptake.⁵ In addition to personal beliefs and outcome expectations, other models of health behavior (i.e., Theory of Reasoned Action⁹) indicate that norms (the opinions of significant others and the importance assigned to those opinions) are important influences on people's self-protective behaviors. For public health interventions to effectively engage individuals of different cultural groups, it is important to understand the potential contribution of norms and personal expectations to behavior change. Members from cultures oriented to the group (collectivist cultures) perceive themselves as an extension of the in-group, whereas members from cultures that emphasize personal accomplishments and individual initiative (individualist cultures) perceive themselves as unique and separate from others.¹⁰ Consequently, decisions of individuals who emphasize the group will tend to be organized around the opinion of important others, and the decisions of individuals who emphasize individual uniqueness and agency will tend to be based on personal opinions and attitudes. For example, research has documented that norms compared to attitudes are more important predictors of health-protective behavioral intentions in Hispanics.^11,12

Researchers have extensively studied parents' and adults' willingness to receive the vaccine and have their children vaccinated. However, little has been done to understand the generalizability of findings of HPV vaccine acceptance studies to participants of diverse cultures.^5,13 This is an important topic because research suggests that culture may moderate previously found associations. A recent study compared predictors of HPV vaccine acceptance in non-Appalachian and Appalachian women. Results indicate that for non-Appalachian women, younger age, lack of a college degree, and residency in a rural county were positively related to vaccine acceptance. On the other hand, for Appalachian women, smoking and having children living at home predicted vaccine acceptance, whereas being married predicted nonacceptance.¹⁴ The results of this study indicate that a one-size approach to promote behavior change may not fit all. Culture matters when considering potential factors to target in public health interventions. The emergence of cultural differences in factors associated with vaccine acceptance suggests that tailoring interventions to culturally diverse populations could help address health disparities in cervical cancer.

Mothers were approached while waiting to be seen by a WIC program coordinator and asked if they would like to answer a brief questionnaire that would determine their eligibility to participate in the study. Mothers who volunteered answered a brief screening questionnaire to check that they met eligibility criteria. Mothers who self-reported being the parents or legal guardians of a daughter between the ages of 6 and 19 who had not been vaccinated against HPV were asked to participate in the study. All study materials were available in English and Spanish.

Participants answered a demographic questionnaire assessing age, number of children and their ages, education level, employment, and insurance status. Participants were also asked if they had previously thought about vaccinating their daughters against HPV and, if so, to name the place where they heard about the HPV vaccine. Prior experience with cervical neoplasia or cancer, HPV, or another sexually transmitted infection (STI) was assessed by asking mothers to indicate if they personally had been diagnosed with cervical cancer or neoplasia, HPV, or another STI and if they knew someone (friend or relative) who had been diagnosed. Response options were yes and no.

Intention to vaccinate daughters was the main outcome measure and was assessed with a measure that consisted of 5 items assessing intention to vaccinate, intention to convince daughter to get the vaccine if she objected, intention to convince a significant other if he or she objected, and intention to talk to a pediatrician or healthcare provider about it. Response options ranged from 1, definitely no, to 7, definitely yes. The Cronbach alpha for the Hispanic group was 0.91, for the non-Hispanic white group was 0.90, and for the African American group was 0.88.

The personal predictors of intention to vaccinate daughters were also assessed. Perceptions of risk were assessed with the following three items: How likely is your daughter to acquire HPV in her lifetime? What are the chances that your daughter will acquire HPV in her lifetime? and What is the probability that your daughter will acquire HPV in her lifetime? Response options for the first 2 items ranged from 1, very unlikely/almost zero, to 7, very likely/almost certain. Response options for the third item ranged from 0 to 100% in increments of 10. The first two items assessing risk perceptions were combined to form one scale. We included a slight variation in wording (e.g., likely vs. chances) in an attempt to capture slight variations in participants' nonquantitative estimates of risk. Interitem correlations were 0.87 for the Hispanic group, 0.93 for the non-Hispanic white group, and 0.84 for the African American group.

Perceived benefits of vaccinating daughters were assessed with the following item: “How effective is the vaccine in protecting against HPV? Response options ranged from 1, not at all, to 7, very much. Severity of acquiring HPV were assessed with the following three items: If your daughter acquired HPV, how severe would the consequences be? How traumatic would it be for your daughter? How embarrassed would your daughter be? Response options ranged from 1, not at all, to 7, very much. Interitem correlations were 0.91 for the Hispanic group, 0.90 for the non-Hispanic white group, and 0.88 for the African American group.

Barriers against vaccinating daughters were assessed with a variety of items asking about the potential side effects of the vaccine, worry that vaccination will lead to early initiation of sexual relations, more sexual activity, discouragement from engaging in other cancer-prevention activities such as cervical cancer screening, number of required vaccine shots, vaccine cost, and daughters' fear of vaccination. Response options ranged from 1, not at all, to 7, very much. Because of low interitem correlations, only the 2 items that assessed sexual-related barriers were combined to form one scale. Interitem correlations were 0.77 for the Hispanic group 0.86 for the non-Hispanic white group, and 0.87 for the African American group. The rest of the items assessing barriers were included in the analyses as individual predictors.

Normative predictors were assessed with the following item: How many of your friends' daughters have been vaccinated against HPV? Response options were none of them, some of them, almost all, and all of them. The extent to which the decision to vaccinate was shared was assessed with the following item: How much of the decision to vaccinate your daughter is up to you? Response options ranged from 1, not up to me, to 7, entirely up to me. This question was followed with an open-ended question that asked participants to state their relationship with the person with whom they shared the decision.

We first conducted a series of regression equations to understand if norms predicted additional variation, beyond that predicted by prior experience with HPV, neoplasia, and other STIs and barriers and health beliefs, in intention to vaccinate daughters across ethnic groups. Thus, we conducted separate multivariate blocked linear regressions for each ethnic group. In step one, we entered the variables that assessed prior experience with HPV, cervical neoplasia or cancer, and an STI using the forced entry procedure. Our rationale for entering prior experience with HPV, cervical neoplasia, or other STIs in the first step was to determine if barriers to vaccination and health beliefs predicted additional variation above and beyond prior experience. In the second step, we entered all the barriers to vaccination and health beliefs. In the third step of the equation, we entered norms. We entered norms in the last step of the equation to understand the percentage of variance that norms would account for after all the hypothesized variables had been included in the model. Our intent was to understand whether normative aspects may contribute differently to the behavioral intentions of members of certain cultural groups.

Table 2 displays participants' prior experience with HPV, cervical neoplasia or cancer, and STIs by ethnic group. Chi-square analyses comparing prior experiences across ethnic groups revealed statistically significant differences in knowing a relative or friend who had been diagnosed with cervical cancer or neoplasia (chi-square=6.90, df=2, p<0.05) and in knowing a relative or friend who had been diagnosed with an STI (chi-square=20.06, df=2, p<0.001). Non-Hispanic white and African American mothers were more likely than Hispanic mothers to know a relative or friend who had been diagnosed with cervical cancer or neoplasia and an STI.

Fifty-five percent of Hispanic mothers (n=27), 50% of African American mothers (n=25), and 70% of non-Hispanic white mothers (n=33) said they had previously thought about vaccinating their daughters. Across the groups, the majority reported that the primary source of information about the HPV vaccine was televised advertisements from a pharmaceutical company (62% of Hispanics, 76% of non-Hispanic white women, and 87% of African Americans). Fifty-five percent of Hispanic, 57% of African American, and 45% of non-Hispanic white mothers reported sharing vaccination decisions with either their daughter, the father of their daughter, or both.

Table 3 presents the results of the first set of analyses for each ethnic group. For Hispanic mothers, norms was the only variable that predicted vaccination intentions. For non-Hispanic white mothers, knowing a relative or friend who has been diagnosed with cancer or neoplasia was a significant predictor of intentions (β=0.33, p<0.01), as were the following barriers and health beliefs: perception that vaccination would lead to increased sexual risk taking (β=−0.45, p=0.06), potential side effects of the vaccine (β=−0.37, p<0.01), and perception of vaccine effectiveness (β=0.52, p<0.001). Norms, however, did not predict additional variation in vaccination intentions in non-Hispanic white mothers. For African American mothers, a prior diagnosis of an STI was a significant predictor of intentions (β=0.38, p<0.05), as were the following barriers and health beliefs: perception that the vaccine could lead to a decrease in other cervical cancer prevention efforts (β=0.74, p=0.07), and perception of daughter's risk of contracting HPV (β=0.36, p=0.05). Contrary to our hypothesis and similarly to non-Hispanic white mothers, norms did not predict additional variation in the vaccination intentions of African American mothers.

Finally, the results of our formal moderation analysis revealed that insurance and education status did not emerge as significant predictors (R²=0.00, p=0.55), and only the interaction term composed of the code comparing Hispanics with the other two ethnic groups and norms (R²=0.11, β=0.33, p=0.02) emerged as significant (Fig. 1). As Figure 1 shows, at 1 SD above the mean for norms, intentions to vaccinate daughters increased significantly for the Hispanic group only (r=0.51, p<0.05).

Overall, the findings of this study are consistent with prior studies in that experience with cervical cancer or neoplasia and personal health beliefs, such as beliefs about vaccine side effects and effectiveness, predict vaccination intentions in non-Hispanic white mothers. Chao et al.¹⁶ observed a modest association between prior experience with STIs and HPV vaccine uptake in a large representative sample. However, it seemed that ethnicity acted as a moderator, as an inverse association was observed for African Americans and an enhanced effect was seen for Asian Americans. These findings point to the importance of stratifying analyses by ethnicity or culture to uncover potential cultural variation in important predictors of vaccination.

In our study, the perception that the vaccine would lead to increased sexual risk taking predicted vaccination intentions only in non-Hispanic white mothers. Past research has produced conflicting findings about the influence on vaccination intentions of the belief that vaccination would lead to sexual disinhibition. Because many controversies surrounding HPV vaccination stem from this very issue, Brewer and Fazekas¹³ attempted to provide an answer through a meta-analysis. Because of the small number of studies available at the time, however, a conclusive answer could not be found. To date, more research has been conducted, and the time may be ripe to attempt to answer this question again.

In our study, the belief that the vaccine would lead to a decrease in other behaviors that protect against cervical cancer, such as screening, emerged as a deterrent of vaccination intentions among African American mothers. The relationship between mothers' attitudes toward other cervical cancer prevention efforts and vaccination intentions deserves further attention. To our knowledge, one study¹⁶ found an association between mothers' own Papanicolaou uptake and attitude toward vaccination. Mothers who are screened frequently have a more positive attitude toward vaccination, although we do not know the mediating mechanisms. Our study suggests that future research should seek to identify the interrelationships among mothers' attitude toward cervical cancer screening, beliefs about the influence of vaccination on screening, and intentions to vaccinate. These factors could be fruitful targets of future interventions to promote vaccine uptake. This is a key issue because of the importance of continued cervical cancer screening after vaccination.

Our findings also shed light on the influence of social norms, an important contributor to health decision making that has been understudied in HPV vaccination research. As hypothesized, social norms emerged as the strongest predictor of intentions in Hispanics. This finding supports our hypothesis that aspects other than those derived from personal health beliefs may be strong contributors to intentions in cultures that emphasize the in-group. Contrary to our expectations, however, we did not find an association between norms and intentions in African Americans, a culture that also emphasizes the in-group.¹⁷ In African Americans, personal experience with an STI was the strongest contributor to vaccination intentions. Although we did not find an association between norms and intentions in African American mothers, the association between intentions and prior experience with an STI underscores the importance of studying the influence of highly salient contextual factors particular to certain ethnic groups on health-related decisions. STIs are a salient aspect for African Americans because they disproportionately affect the African American community. The HPV vaccine protects against the most common STI, and public health interventions targeting African Americans that highlight this fact may be more persuasive than those that only highlight the protection that the vaccine offers against cervical cancer. This speculation is supported further by the association found between perceptions that daughters are at risk of contracting HPV and vaccination intentions in African American mothers.

Our study has several limitations. First, we used a small convenience sample at one point in time. This limitation restricts the generalizability of our results. Consequently, our recommendations should be taken with caution until supported by further research. Second, we focused on intentions to vaccinate rather than on actual vaccine initiation and completion. Third, gender may moderate the associations of theoretical tenets and intentions, and we only surveyed mothers. Fourth, our measures of prior diagnosis of cervical neoplasia or cancer and STIs were self-report and, thus, may have been subject to social desirability effects. Finally, although we attempted to control for demographic factors, such as income, by recruiting mothers who were receiving WIC services, demographic differences were present in education level and insurance status. Moreover, we did not measure actual income and key cultural constructs, such as collectivism. Future studies should recruit a random stratified sample from each ethnic group, use a longitudinal design to study vaccine initiation and completion, include other key decision makers, and assess such important demographic factors as income, and key cultural constructs to investigate plausible moderation and mediation effects.