In this study, we explored factors influencing mothers’ decisions to vaccinate 11- to 12-year-old daughters against HPV and daughters’ and mothers’ perspectives about the decision-making process. The findings have implications for the design of interventions for mothers, girls, and clinicians to increase vaccination of 11- to 12-year-old girls. We found that the primary factors influencing a mother’s decision to vaccinate her 11- to 12-year-old daughter against HPV were her own health-related beliefs and experiences; interactions with clinicians, friends, and family members; and exposure to media reports or marketing about HPV vaccines. The majority of mothers reported that they had made the decision to vaccinate; in contrast, most girls thought that the decision was mutual.
A mother’s personal health-related beliefs appeared to be the principal factor influencing her decision to vaccinate her daughter. The role of HPV vaccines in protecting her daughter’s health, and especially in preventing cervical cancer, was the most important of these beliefs. This finding is supported by a number of previous studies examining acceptability of HPV vaccines among parents.7,9,15–17,24
The concept of anticipated regret—that is, concern about future remorse if a child were to develop HPV-related disease and had not been vaccinated—was commonly noted; this is consistent with the work of Ziarnowski et al.25
Many of the mothers also noted that vaccinating 11- to 12-year-old girls was important, and this belief was often driven by a belief that the vaccine should be administered before sexual maturity and sexual initiation, and thus exposure to HPV. This is consistent with the finding in previous studies that mothers who perceive their daughters to be at risk for HPV are more likely to accept vaccination of younger daughters.7,14,16
Furthermore, having had personal experience with HPV or cervical cancer appeared to increase a mother’s perception that her daughter was susceptible to HPV and her acceptance of vaccinating a younger daughter, as has been shown previously.16
The implications of these findings are that interventions to promote vaccination of 11- to 12-year-old girls should focus on the health benefits of HPV vaccination, especially cancer prevention, and the importance of vaccinating at this age. It is essential for clinicians to be comfortable discussing the specific reasons why vaccination at 11 to 12 years of age is recommended—that is, vaccination prior to HPV exposure is critical to maximize effectiveness and adolescents are susceptible to HPV infection—especially with mothers who wish to delay vaccination.
Interactions with clinicians, friends, and family were a second key driver of a mother’s decision to vaccinate her young daughter. Numerous studies have demonstrated the central importance of a clinician’s recommendation in a mother’s decision to vaccinate her child against HPV,9,16,24,26
but few have explored what aspects of the clinician–mother interaction are most important. We found that the most influential features of this interaction included a clinician broaching the topic of HPV vaccination prior to the actual vaccination visit, a clinician providing key information about vaccine safety and efficacy, and a discussion of HPV vaccination in the context of a trusting, respectful relationship. These findings suggest that a mother’s decision to vaccinate a young adolescent is a process, often multistep, that is facilitated by a clinician who educates the mother and elicits her concerns, and who gives her time to consider the decision and return at a later date for vaccination. These practices may give a mother a sense of empowerment and confidence that she has the information needed to make the best decision for her daughter.
Exposure to media and marketing regarding HPV vaccines, especially television commercials, was a third major factor influencing mothers’ decisions to vaccinate. Media and marketing exposure drove a mother’s decision by raising her awareness about HPV vaccines, educating her about HPV and HPV vaccines, triggering discussions with her daughter about vaccination, convincing her of the benefits of vaccination, and encouraging her to seek out additional information about HPV vaccines. Our finding that the media plays a significant role in mothers’ decision making about HPV vaccination is not surprising, given the central role that the media plays in increasing public awareness about medical advances such as new vaccines.27
However, this information is not always accurate or comprehensive. A study of online media coverage of HPV vaccines conducted in 2006 revealed that critical information about the vaccine, including data about vaccine safety and duration of protection, was consistently missing from media coverage, and that inaccurate information was frequently presented.28
Since that time, a number of unsubstantiated and misleading media stories about the purported risks of HPV vaccination have appeared. It will be important for clinicians not only to advocate for factual, balanced messages about the benefits and risks of vaccination but also to advocate for accurate and responsible media coverage of vaccine-related topics.29
Furthermore, it is essential that clinicians are able to provide parents with accurate information about vaccines, including links to reputable Web sites.
The majority of mothers reported that the decision to vaccinate was primarily theirs and explained that their daughters looked to them for guidance and trusted them to make health-related decisions. Their daughters tended to believe that they had insufficient knowledge about vaccination on which to base a decision about vaccination; this is likely true for other vaccines as well. Previous studies of adolescents similarly found that girls lacked basic knowledge and understanding of HPV vaccines.30,31
Mothers who make the decision to vaccinate their daughters without including any discussion or education may believe that their daughters are looking to them to make the decision and that they have her best interests in mind. However, they may be missing a valuable opportunity to educate their daughters about the importance of vaccination in preventing disease and the role that HPV vaccines can play in preventing cervical cancer, as well as to encourage their daughters to begin to make their own health-related decisions. Higher level of vaccine-related knowledge has been shown to be associated with HPV vaccination among high school students,30
and mother–daughter communication about sex has been shown to be positively correlated with HPV vaccination among daughters.32
A barrier to mothers educating their daughters may be their own lack of knowledge and understanding about HPV and HPV vaccines.17,30
Clinicians are in a unique position to address these barriers by educating mothers so that they can effectively communicate information about vaccination to their daughters, and by encouraging mothers to discuss vaccination with their daughters and involve daughters in the decision-making process.33
Most daughters in our study reported the vaccination decision was mutual, as has been shown in a previous study of 12- to 13-year-old girls in Manchester,34
and these girls frequently stated that the decision-making process involved mother–daughter discussions about HPV vaccination. Our findings suggest that girls who have discussions with their mothers about HPV vaccination tend to view the vaccination decision as a mutual one, regardless of the mother’s opinion. Our findings contrast with those of Hughes et al,35
who found that in a sample of 11- to 18-year-old girls and their mothers, many girls considered themselves passive participants in the decision-making process. The difference in findings may be due to the fact that more than half of the girls in the study by Hughes et al had not received the HPV vaccine, and if mothers made the decision not to vaccinate their daughters, this may result in little discussion about vaccination, leading to a sense among daughters that they were not involved in the decision-making process.
Mother–daughter discussions about vaccination and health-promoting behaviors not only provide girls with essential health-related information but also may help them feel empowered to begin to take responsibility for future health-related decisions, including decisions about sexual health. In the Manchester study, the great majority of girls reported that vaccination made them aware of the risks of having sex and reported that they felt better informed to make decisions about future sexual behavior.34
In a study involving mothers of 11- to 12-year-old girls, 81% of mothers reported discussing HPV vaccination with their daughters, and 47% of those mothers reported that the discussion led to a conversation about sexual health, primarily among those daughters whom the mothers perceived to be sexually active.36
These findings suggest that in contrast to the frequent media reports focusing on parental concern about HPV vaccination leading to riskier sexual behaviors, and evidence that clinicians believe that parents are concerned about this issue,10
many mothers are in fact using the HPV vaccination visit as an opportunity to discuss STI prevention and sexual health. As some parents may not feel comfortable discussing issues of sexuality with their daughters, clinicians may be able to help encourage parents to recognize this “teachable moment” as a valuable opportunity to promote healthy behaviors in their children.18,37
The findings of this study must be interpreted in the context of several limitations. First, we only enrolled daughters who had received the HPV vaccine in a clinical setting and therefore were only able to characterize factors influencing a decision to vaccinate in this specific study sample. In addition, the study was conducted in clinical settings, and thus the findings may not be as relevant for vaccines delivered in other settings, such as school-based health centers. We only enrolled mothers who agreed to HPV vaccination, limiting the relevance of these findings to mothers who have not agreed to vaccination. Finally, we conducted the study in a relatively small number of mothers and daughters, and in a limited geographic area. However, as a qualitative study, the intent was not to generate findings that could be readily generalized to a larger population, but rather to characterize, in detail, the decision-making processes involved in HPV vaccination in a specified group of mother–daughter pairs.