The great majority (91%) of low-income, minority parents in our study intended to accept vaccination for their daughters, and nearly all followed through on this intent: 89% of all girls received vaccination within 1 year of study participation. Black, White, and Latino parents all expressed high levels of support for HPV vaccination, and racial differences in vaccine acceptance were not apparent. In addition, pre-existing knowledge of HPV did not seem to impact vaccine acceptance. Our qualitative data provided an opportunity for parents to expand upon formal attitude assessments. Although several expressed concerns about possible side-effects and discussed complex feelings associated with vaccinating against a sexually transmitted infection, for the most part these concerns did not prevent them from vaccinating their girls.
Parents’ intention to vaccinate was high compared with hypothetical acceptance rates published prior to HPV vaccine availability (13
), and the proportion of girls receiving HPV vaccine in our cohort exceeded the national average (12
). Some of this difference may be due to healthcare access. All girls ages 11–18 at our institution have insurance coverage for HPV vaccination, vaccine is ordered easily through the electronic medical record, and it is stocked in the pediatric and adolescent clinics. In addition, our qualitative data indicated that most parents were excited to be able to prevent cervical cancer with HPV vaccination, and they were not inhibited about vaccination because HPV is sexually transmitted. In fact, some parents strongly favored HPV vaccination because of the stigma associated with contracting a sexually transmitted infection. Studies with different populations have also found that most parents who support vaccination are primarily concerned with protecting their daughters from diseases (16
), but emphasized different reasons for declining vaccination, including a low perceived risk of infection, which was rarely raised by our participants.
If high levels of parental acceptance for HPV vaccine among minority parents translate into high vaccination rates on a national level, health disparities in cervical cancer incidence and mortality could be reduced. Over 90% of children in the U.S. receive routine childhood immunizations, and, although poverty has been associated with undervaccination, some studies suggest that vaccination rates are similar among different racial/ethnic groups (19
). In addition, vaccination has successfully reduced racial disparities in other diseases (9
). Current cervical cancer prevention practices require asymptomatic, adult women to present for frequent vaginal examinations. Because minority women often have lower levels of health insurance coverage (21
) and may be skeptical of medical interventions (25
) or hold fatalistic attitudes towards cervical cancer screening (27
), childhood vaccination may be more successful than Pap smear screening for reducing disparities in cancer rates among vulnerable women.
Our findings have several limitations. We studied a small, non-randomized sample of parents attending medical visits with their children, and the results may not generalize to other populations or settings. Parents who agreed to participate in the study may also have held more positive views toward vaccination than those who did not wish to participate or those not presenting with their daughter for care. As all parents were seeking medical care for their children, results may not be applicable to parents who do not access the healthcare system. However, our study was performed in a large safety-net hospital in a state where everyone is required to have health insurance; in addition to the variety of private and public options, our institution also provides care to uninsured illegal immigrants, which allowed us to speak with parents who would not have had healthcare access in other settings. The small number of parents who declined vaccination limited our ability to assess the independent contributions of factors such as race, country of origin, education, religion, or the age of the daughter or parent on parental views toward HPV vaccination. Such questions are better answered by well-designed population-level surveys. We did not assess vaccine completion rates in this study because different factors may be involved with series completion than with initiation, such as clinical scheduling practices and patient reminder systems. Our goals with this qualitative study were to understand in depth how a cohort of low-income and minority parents views HPV vaccination and to create an interpretation of ideas which might be useful to understand why parents in other settings may accept or decline HPV vaccination.
We did not seek to intervene with these parents. However, they were provided with a 100 word informational paragraph about HPV prior to asking their opinion on HPV vaccination so that they could understand the questions being asked, as is commonly done in studies of HPV vaccine acceptance (16
). We obtained the information used in our paragraph from the CDC Vaccine Information Sheet on HPV vaccine (30
); these sheets are routinely given at medical visits when vaccines are recommended. The possibility of influencing HPV vaccine acceptability via the educational paragraph could be considered a limitation. However, recent literature indicates that knowledge does not correlate well with vaccine acceptance (14
), and written information, such as that given in our study, does not appear to influence HPV vaccine acceptance (19
If replicated in larger studies, positive opinions toward HPV vaccination among low-income and minority parents could be leveraged when designing public health programs that use vaccination to reduce racial disparities in cervical cancer incidence.