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In the United States, Latinas experience higher incidence and mortality from cervical cancer than non-Hispanic white women.1 Underutilization of Papanicolaou (Pap) testing for cervical cancer screening among Latinas plays a major causal role in this disparity,2 as the majority of cervical cancer deaths are preventable with routine Pap testing and patient follow-up care.3 Another strategy for the prevention of cervical cancer is now available with the approval of two human papillomavirus (HPV) vaccines by the U.S. Food and Drug Administration in 2006 and 2009. Public education programs that use tailored, evidence-based communication strategies to target high-risk groups are critical to ensure acceptance and uptake of the HPV vaccine by those most at risk for cervical cancer.4
Less acculturated Latino parents with lower levels of English-language proficiency may be less likely to be exposed to comprehensible educational materials related to cervical cancer than individuals with higher levels of English-language proficiency.5–8 Low levels of HPV and HPV vaccine awareness and knowledge among Latinos in a variety of U.S. regions have been demonstrated in several studies.9–11 However, a number of studies showed that when the HPV vaccine is presented as a strategy to prevent cervical cancer, support for vaccine uptake is high among Latinas and Latino parents.10,12,13
Collaborations with community-based partners who can inform the style, content, and relevancy of cancer education messages result in the most effective cancer prevention outreach efforts.14 One effective culturally tailored health education outreach strategy to target Latino communities is the use of novelas (short stories) for television, radio, and print. Novelas that are developed with Latino community input have been successful at promoting health education messages on human immunodeficiency virus and alcohol use to Spanish-speaking communities with low levels of literacy.15,16 The success of novelas within Latino communities in the U.S. may in part be the result of the implementation of novelas as effective health-promotion strategies in Latin America.17,18
In general, qualitative methodology has been shown to be a useful and valid strategy to develop the content of health education programs targeting Latinos. One study successfully used focus groups (FGs) and community meetings with community members and key leaders to develop a telenovela (short story or mini-drama produced for television), radionovela (short story or mini-drama produced for radio), and fotonovela (short story or mini-drama in the form of a photo pamphlet vignette), all with one storyline, to improve communication between parents and youth and youth attitudes regarding alcohol use within a Latino community.16
This is one of the first studies conducted on the development of a culturally appropriate radionovela to improve HPV and HPV vaccine knowledge and attitudes among Latino parents that employs Grounded Theory methodology related to the analysis of in-depth elicitation interviews and FGs. Furthermore, it is the first study to (1) explore the in-depth perspectives of Latino parents on a sensitive topic related to adolescent sexual health and (2) use these findings to develop a culturally tailored public health intervention to address parental concerns. The methodology employed in this study may be useful to other public health practitioners who are hoping to develop a tailored public health intervention on a new public health topic for a specific target population.
This study took place in the Lower Yakima Valley of Washington State, a region that includes many small agricultural communities, has a population of about 62,000, and is more than 50% Latino. Latinos in this region are primarily of Mexican American ethnicity.19
From June 2008–January 2009, Latino parents or guardians of daughters aged 9–14 years were recruited to participate in in-depth elicitation interviews (EIs). The themes generated from the EIs were used to develop four fotonovelas to inform the development of a radionovela to raise awareness of HPV and the HPV vaccine among Latino parents. In April–July 2009, Latino parents of daughters aged 9–14 years who had not participated in the EIs were recruited to participate in FGs to provide feedback on the four Spanish fotonovelas that were used to develop a Spanish radionovela and on the produced radionovela itself.
Participants were recruited by Spanish flyers with phone number tear-off tabs posted in local community gathering places such as churches, stores, and organizations.20
EIs were conducted in a location that was convenient for the participant; most chose their own home. All EIs were in Spanish and lasted approximately 30–45 minutes. The interviews included a series of semistructured, open-ended questions and probes for further information. The EIs explored sociocultural decision-making processes, barriers, and facilitators of receiving HPV vaccination for their daughters.
EIs differ from other interviews in that they aim to convince the interviewee to share factors related to the particular behavior under investigation (i.e., intention to vaccinate daughter) without pressure on the interviewee to respond in a socially desirable manner.21 Furthermore, the interview guide was continuously revised following ongoing data analysis activities to most effectively elicit beliefs, knowledge, and attitudes related to cervical cancer, HPV, and uptake of the HPV vaccine.
Earlier versions of the guide assumed higher levels of participant exposure and familiarity with cervical cancer, HPV, and the HPV vaccine than existed. Later versions of the guide included the same overarching questions, but were better able to capture participant exposure and knowledge levels because they included additional probes to gather more specific and in-depth information. For example, a previous version asked, “Where have you heard about the HPV vaccine?” and a later version also asked, “Have you heard about the HPV vaccine from a health provider? A media source? A friend? A family member? From school? From any other person or place?” Lastly, a short demographic survey was included. Following completion of the EI, participants received a $20 gift card as compensation for their time. All interviews were recorded, transcribed in Spanish, and then translated into English.
Ongoing qualitative data analysis activities took place following transcription and translation of the EIs. We used Atlas.ti version 5.5 to conduct all data analysis activities.22 This investigation employed Grounded Theory to explore the themes that emerged from the EIs. Grounded Theory is able to capture sociocultural contexts because it is a systematic qualitative methodology that allows a theoretical framework to emerge from the data through the process of conducting research and data analysis.23 Thematic coding and data analysis was completed by the primary investigator for this study. A subsample of the interview transcripts (n=3) was coded by two other investigators to confirm classifications, descriptions, and thematic interpretations of the findings. High rates of agreement levels were present, with only minor discrepancies in coding found among the three investigators.
Following EI data analysis, from August 2008 to July 2009, four Spanish-language HPV vaccine fotonovelas were produced in collaboration with a local public radio station, Radio KDNA. Radio KDNA is the oldest and largest Spanish-speaking community radio station in Washington, serving a five-county region focused on the Yakima Valley (south-central Washington). It is housed in the Northwest Communities Education Center (NCEC) located in Granger, Washington. Started as a farm worker education and advocacy project, NCEC has literacy and English-as-a-second-language programs, other community services, and radio programming. Its radio shows are in Spanish and make frequent use of radionovelas.
Three FGs were conducted with parents of daughters aged 9–14 years to explore the themes and content of the four HPV vaccine fotonovelas. Participants responded to open-ended questions related to perception, content, and impact of the fotonovelas. One question was, “What is the main message of this fotonovela?” This probe was repeated during the presentation of each fotonovela. The FGs were conducted by trained Spanish-speaking Latina facilitators and included the participation of a Spanish-speaking note-taker. Following the completion of these fotonovela FGs, the qualitative data were analyzed to critically assess the strengths and weaknesses of the health-promotion materials. This feedback was used to inform the development of the final radionovela in collaboration with Radio KDNA. Lastly, a radionovela FG was held to provide feedback on the produced radionovela. In addition, FG participants completed short demographic questionnaires. Following participation in the FG, participants received a $20 gift card as compensation for their time.
The EI participants included 36 Latino parents/guardians of daughters aged 9–14 years (25 women and 11 men) (Table 1). Nine of the parents (25%) expressed that they had already received at least one of the three-dose HPV vaccines for their daughters prior to participating in the EI (data not shown). The FG participants included 33 Latino parents of daughters aged 9–14 years (22 women and 11 men). Most of the participants demonstrated low levels of acculturation as assessed by the Short Acculturation Scale24 (Table 1). More than half of the FG participants (60%) had previously heard of the HPV vaccine (data not shown).
From our Grounded Theory qualitative data-coding activities, a number of themes emerged from the EIs that were used to develop four fotonovelas (Tables 2 and and3).3). Data collected evolved into a theme if the data represented a salient factor affecting participant awareness and interest in the HPV vaccine that emerged within and across participant interviews.
Overall, participants demonstrated low levels of awareness of HPV and the HPV vaccine. About one-third (33%) of the participants had not yet heard of the HPV vaccine, and more than half (56%) were unfamiliar with the major cause of cervical cancer (Table 2).
A large portion of participants indicated that they received health information from a physician or nurse at a local clinic (39%) and had a regular physician (44%). Many participants appeared to trust their physicians and have confidence in the information that they received from their health clinics. Furthermore, many participants expressed that they received health information from their family members or friends (31%) (Table 2).
We found that when informed of the HPV vaccine, parents expressed a range of perceived barriers related to making the decision to vaccinate their daughters. Many parents felt that their daughters were too young to receive a vaccine to prevent a sexually transmitted infection such as HPV (19%). Furthermore, a large portion of the parents were concerned about the vaccine's possible side effects (36%) (Table 3).
Nearly all EI participants felt comfortable speaking with a medical provider (e.g., nurse or physician) about the HPV vaccine (97%). Many parents would talk with their daughters' other parent (25%), with their daughter (19%), and/or with another friend or family member (25%) before making a decision for their daughter to receive the HPV vaccine. The majority of parents felt that their daughter was of an appropriate age to receive the vaccine (56%) (Table 3).
Following data analysis from the EIs, the generated themes were used to develop four fotonovelas with Radio KDNA. Each fotonovela took the shape of a trifold pamphlet that included a series of large photos that told a story using brief dialogues. The four vignettes included:
Three FGs were held with 17 women and 10 men to receive feedback on the four sample fotonovelas. The order of discussion of each fotonovela was randomized during each of the three FGs. Overall, participants learned a lot of new information from the fotonovelas. After reviewing each fotonovela, participants were motivated to ask more questions about HPV and the HPV vaccine. Participants were most strongly impacted by fotonovelas #1 and #2 because they learned the most from them and found their themes to be more culturally familiar. These two novelas were used as the foundation for the radionovela text, which was then produced in collaboration with Radio KDNA. In addition, participants wanted a fact box on the back panel of the fotonovela that included more HPV and HPV vaccine facts, as well as resources for additional information.
The last FG included five women and one man. They listened to the produced radionovela and provided their feedback. Only two of the individuals had previously heard of the vaccine. The participants responded positively to the radionovela and found all the facts to be useful. They especially appreciated the inclusion of a father and a physician. They enjoyed the length (about five minutes) and all of the content. The radionovela sparked interest and questions related to HPV and the HPV vaccine. Overall, the participants found the radionovela to be a helpful health-promotion strategy.
To the best of our knowledge, this is the first study to use qualitative methodology to develop a Spanish radionovela aimed at improving awareness, knowledge, and interest related to HPV and the HPV vaccine among Latino families. Novelas represent a culturally tailored mechanism to convey HPV and HPV vaccine information in a meaningful way that may have a strong impact on Latino parent knowledge and perceptions related to the HPV vaccine. Novelas are useful health education tools because they are able to promote health education messages to Spanish-speaking communities with low levels of literacy by integrating characters into a short and simple drama that is embedded within a familiar sociocultural context. Furthermore, novelas are easy to disseminate to communities via radio, video, and/or print media.
The products produced as a result of this study have been used to promote awareness of the HPV vaccine among Latino parents in the Yakima Valley of Washington. The two fotonovelas were produced as high-quality pamphlets with professional photography for widespread dissemination at community events, home health parties, health clinics, and schools. The radionovela was aired at least three times per day for three months from September to November 2009 on Radio KDNA. Prior to the airing of the radionovela, an efficacy evaluation was completed. Latino parents of daughters aged 9–17 years (n=88; 78 mothers and 10 fathers) were randomized to listen to the HPV vaccine radionovela or to another public service announcement. Participants completed a 30-minute pretest/posttest questionnaire. The HPV vaccine radionovela improved HPV and HPV vaccine knowledge and attitudes among rural Latino parents.25 However, further investigation is needed to assess the widespread impact of the fotonovelas and radionovela on HPV and HPV vaccine awareness and uptake among Latino parents in the Lower Yakima Valley.
The fotonovelas and radionovela aimed to increase HPV and HPV vaccine knowledge and awareness. Knowledge related to HPV and the HPV vaccine may be a key predictor of HPV vaccine uptake. A few studies have demonstrated that parents with higher levels of HPV and HPV vaccine knowledge are more likely to have given permission for their daughters to receive the HPV vaccine26,27 and are more likely to support vaccine uptake for their daughters.28,29 Note that these studies have included very few or no U.S. Latino parents and were cross-sectional in design. More research is needed to investigate HPV knowledge-based factors related to HPV vaccine uptake among Latino parents in the U.S. As previously discussed, past studies have demonstrated that Latino parents and Latinas who are informed of the HPV vaccine are supportive of HPV vaccine uptake.10,12 Furthermore, one study demonstrated that Latina mothers noted lack of information as an important reason to not support HPV vaccine uptake.10
In addition, the themes that emerged from our EIs are similar to others. Specifically, in a population-based survey from the 2008 Child Health Assessment and Monitoring Program for 617 parents in North Carolina that investigated factors related to HPV vaccine initiation, rural parents were significantly less likely to have allowed their daughters to be vaccinated than urban parents (21.3% vs. 35.5%). The most common reasons for not allowing their daughters to be vaccinated were the need for more information, the belief that one's daughter was too young, and concern about the vaccine's safety or side effects.30
This study was subject to one limitation: the use of a convenience sample to develop and evaluate the fotonovelas and radionovela from a distinct region of Washington State. As a result, these findings and products may not be as useful to Latinos residing in other regions of the United States. Further evaluation of product impact would be needed.
Latino parents demonstrated overwhelmingly high interest in learning more about the HPV vaccine. For Latino parents to take action and learn more about the HPV vaccine, more culturally tailored health-promotion programs such as this one need to be conducted in other Latino communities. Furthermore, the methodology employed in this study may be useful to public health practitioners nationwide aiming to develop effective health education tools on new and important public health issues for specific target communities and populations.
Dr. Kepka gratefully acknowledges funding from the National Cancer Institute (NCI) Cancer Education and Career Development Program (R25 CA92408) as a Biobehavioral Cancer Prevention and Control Pre-Doctoral Fellow in the Department of Health Services at the University of Washington and at the Fred Hutchinson Cancer Research Center. Dr. Kepka has also received funding from the Agency for Healthcare Research and Quality (T32 HS013853) for some of the work on this study. The radionovela to Address Cervical Cancer and the HPV Vaccine for Rural Hispanics was a supplemental pilot project to the National Institutes of Health/NCI funded by the Community Network Program, Hispanic Community Network to Reduce Cancer Disparities (U01 CA114633). This study was approved by the Fred Hutchinson Cancer Research Center's Institutional Review Board. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the funding agencies.