In this qualitative study of ethnically diverse parents, knowledge and awareness of HPV and the vaccine was low. Parents almost universally reported feeling that they did not have sufficient information to make an informed decision about vaccinating their daughter(s). Concerns about vaccine safety and potential side effects were also prevalent. Often, these concerns were discussed in the context of mistrusting pharmaceutical companies and a concern that the vaccine is being promoted solely for profit. In these respects, our findings are consistent with recent studies of parental knowledge and attitudes toward the HPV vaccine [5
Our findings shed new light on parental desire for, and experiences with participation in decision-making. Although this study was not specifically designed to test differences in opinion across gender or racial/ethnic groups, we noted variations in themes between groups.
Hispanic mothers more often reported minimal involvement in decision-making despite a desire to take an active role. Most Hispanic and African American men preferred to defer decisions to female caretakers. Whereas Hispanic mothers reported more concern over birth defects and reproductive health. Parents in all groups reported learning about HPV from media sources, yet almost all reported a preference for receiving information from their daughter's health care provider.
Prior to discussion of potential implications, limitations of this study must be noted. This was a sample of convenience, which limits the generalizability of our results. Our goal, however, was not to obtain a representative sample, but rather to hear from parents from a variety of backgrounds and who had diverse perspectives and experiences. It is possible that study volunteers were more interested in HPV and more knowledgeable about the topic compared to the general parent population. If, indeed, participants are assumed to be more knowledgeable than the general population, these findings further emphasize the need for HPV vaccine interventions, as levels of knowledge and awareness were low. Lastly, we were not able to explore inter-ethnic differences across racial groups (e.g., by country of origin or region). We recognize the heterogeneity within each of the groups but were limited in our analysis by sample size. Nevertheless, our data are useful in generating hypotheses that can be tested in future research and for informing health communication intervention development [6
There are several important implications of this research. Parents need additional information about the vaccine, its benefits, and limitations. Parental reports of inadequate information or involvement in decision-making is cause for concern for many reasons. First, participation of parents in vaccine decisions could increase providers' abilities to assess risks of side effects. For example, providers need to be alerted to a child's allergies or any major illnesses, which could affect vaccine response [2
]. Second, parents need to be informed of the potentially serious (but rare) allergic reactions that can occur, as well as the limitations of the vaccine (i.e., it does not protect against other sexually transmitted infections). Third, increased parental knowledge about the vaccine could result in improved rates of vaccine series completion. Currently, most who initiate the vaccine's series fail to receive the required three-dose regimen [12
Parents reported a strong preference to receive HPV-related information directly from their daughters' health care provider. As such, interventions aimed at improving provider communications with parents about HPV are needed. Provider endorsement has been found to be an important driver of HPV vaccination in previous studies [5
]. Providers need information and skills to effectively disseminate accurate information, help manage parental uncertainty, respond to emotional concerns, and facilitate informed decision-making among parents. However, given the mistrust expressed among some groups toward providers, interventions will also need to foster strong provider-patient relationships. While time constraints are a potential barrier to developing relationships with parents, there are ways to address this. For example, provider vaccine recommendations can be followed by reminder mailings and parent education on how to best prepare for a clinical encounter.
Our finding that female caregivers often hold primary responsibility for health decisions, particularly in relation to the sexual health of their daughters, highlights the importance of targeting HPV health communications. For example, the importance of vaccinating young girls could be discussed with mothers when they themselves present for cervical cancer screening. In addition, the finding that many parents rely on female family members and friends for input on health-related decisions suggests that targeting key members within an individual's social network could be potentially effective for the dissemination of HPV vaccine information and adherence to provider recommendations.
Finally, to address parental mistrust of pharmaceutical companies, it will be important to deliver interventions that are not associated with or financially tied to the pharmaceutical industry. This may help to improve program credibility and mitigate mistrust. Given some of the public's mistrust of vaccines in general, providing information through trusted and credible sources will be critical.
In conclusion, given that there is variation among ethnically diverse parents in the degree of desired involvement in decision-making, it would be prudent for providers to inquire about and respect preferences for involvement. Understanding the diverse models of parental decision-making about HPV vaccination would enable the development and evaluation of much needed targeted health communication interventions to promote vaccine uptake and completion.