Factors Associated With African American Mothers’ Perceptions of Human Papillomavirus Vaccination of Their Daughters: An Integrated Literature Review
Problem Identification: African American (AA) women have a higher mortality rate for cervical and other cancers and are less likely to have received the human papillomavirus (HPV) vaccine than White women. Mothers play a significant family role and have a unique relationship with their daughters. Mothers’ positive views on HPV vaccination may enhance the HPV vaccination rate among their daughters.
Literature Search: The review was conducted by searching literature in PubMed®, CINAHL®, ScienceDirect, Ovid MEDLINE®, and ProQuest databases. The search was limited to studies conducted in the United States and published since the inception of the HPV vaccine in 2006.
Data Evaluation: Of 10,566 publications retrieved, 28 articles were included in the final sample.
Synthesis: Factors associated with HPV vaccination were approval and disapproval of HPV vaccination from physicians, family, and friends; HPV knowledge; attitude and belief about HPV vaccination; benefits of vaccination; and challenges of and barriers to HPV vaccination.
Implications for Practice: Understanding factors related to HPV vaccination decisions among AA mothers will inform healthcare providers of the best approach to improving vaccination rates among this high-risk population.
Human papillomavirus (HPV) is a key cause of the following six cancers: cervical, vulvar, vaginal, anal, penile, and oropharyngeal cancers (American Cancer Society [ACS], 2020). HPV is the most common sexually transmitted viral infection affecting both men and women (ACS, 2020). In the United States, 14 million new cases of HPV are reported every year, and about 80% of people will get an HPV infection in their lifetime (Centers for Disease Control and Prevention [CDC], 2019).
The latest version of the HPV vaccine (Gardasil®9) was approved in 2016 by the Advisory Committee on Immunization Practices (ACIP); the immunization covered nine strains of HPV (6, 11, 16, 18, 31, 33, 45, 52, and 58) (CDC, 2020). According to the CDC (2019), Gardasil 9 was routinely recommended for males and females aged 11–12 years but can be administered from ages 9 through 26 years. Two doses of Gardasil 9 are required for preteens aged 9–14 years, with 6–12 months between each dose, and teens and young adults aged 15–26 years can receive three doses scheduled at 0, 2, and 6 months. In June 2019, the ACIP recommended HPV vaccination to individuals aged 27 through 45 years who were not already vaccinated (CDC, 2019).
The HPV vaccine has been effective in preventing cancer-causing infections and precancers (CDC, 2019). The infections with HPV-related cancers and genital warts have reduced by 86% among teen girls and 71% among young adult women (CDC, 2019). There was a 40% reduction in cervical precancer caused by HPV infection among women vaccinated with the HPV vaccine (CDC, 2019).
Despite the HPV vaccine’s effectiveness, the rate of vaccine remained below 80% of the Healthy People 2020 target (Townsend et al., 2017). The national rate of initial doses of HPV vaccinations has increased from 68.1% in 2018 to 71.5% in 2019; however, the national rate of completion of the three-dose vaccine series remains low at 51.1% in 2018 and 54.2% in 2019 (Elam-Evans et al., 2020). African American women are 10% less likely to have received the HPV vaccine than White women, and the vaccination rate for non-Hispanic Black individuals was 38% compared to 44.7% for non-Hispanic White individuals in 2015 (Williams et al., 2017). These HPV vaccination rates are much lower than in other countries, such as Australia, where the girls’ vaccination rate remains at 79% (Hall et al., 2019).
African American women have the highest mortality rate as compared to other racial/ethnic groups in the United States for cancer (ACS, 2019). The incidence of cervical cancer is 30% higher in non-Hispanic Black women than in non-Hispanic White women; in addition, non-Hispanic Black women are 80% more likely to die from cervical cancer than non-Hispanic White women (ACS, 2019).
African American mothers play a significant role in the family and have strong relationships with their daughters, and this plays an important role in increasing resilience, which helps daughters to develop effective self-worth, self-esteem, and coping strategies (Everet et al., 2016). This mother–daughter bond may enhance the HPV vaccination rate among this population. Therefore, African American mothers are in the best position to discuss HPV vaccination and cervical cancer prevention with their daughters. There is a significant need to improve HPV vaccination uptake among this high-risk population. The purpose of this review is to examine factors associated with the maternal perceptions of HPV vaccination among African American daughters in the United States.
This literature review aims to synthesize factors associated with the maternal perception of HPV vaccination among African American mothers. This information can inform the development of an intervention for this high-risk population and provide direction for future research studies. The following PICO question guided the search: What factors affect African American mothers’ perceptions of HPV vaccination of their daughters? The literature review synthesis was guided by the Health Belief Model (HBM) construct (perceived susceptibility, perceived benefit, perceived barrier, perceived severity, cues to action, and self-efficacy) (Rosenstock et al., 1988). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was used in this integrative literature review (Moher et al., 2009).
The qualitative, quantitative, and mixed-methods studies of HPV vaccination among African American mothers and daughters published in the English language between 2006, when the U.S. Food and Drug Administration (2019) approved the first available HPV vaccine for girls, through the date of the final search (December 30, 2020) were included. Reviews were excluded if the study had African American boys because the focus was on African American mothers and daughters. The review’s primary purpose was to explore the maternal perception of HPV vaccination of their daughters after 14 years of HPV vaccine development for girls. The review’s findings can be used to compare future reviews and interventions for adolescent male vaccinations among this high-risk population. However, research studies were included if the sample had at least 20% African American females in combination with other races, such as Hispanic, Haitian, Caribbean, and White. Studies were also included with fathers, as long as the sample consisted of more mothers than fathers. Research commentary papers, expert opinions, dissertations, and case studies were excluded.
Information Sources and Search
The review was guided by Whittemore and Knafl’s (2005) methodology, and it consisted of the following five stages: problem identification, literature search, data evaluation, data analysis, and presentation of findings. The studies were evaluated using the Johns Hopkins Research Evidence Appraisal Tool (Johns Hopkins Medicine, 2017). The first author developed search strategies in consultation with a school librarian who is knowledgeable about developing and documenting search strategies and identified keywords using MeSH (Medical Subject Heading) terms. A comprehensive search was conducted using CINAHL®, PubMed®, Ovid MEDLINE®, ProQuest, and ScienceDirect. The keywords used were human papillomavirus or papillomaviridae, immunization or vaccination, African Americans or Black, mothers or parents, perception, and psychology. An ancestry search of the reference list of retrieved articles was manually conducted for additional articles.
Study Selection and Data Collection
The initial search yielded a total of 10,566 articles; among the articles, 3,628 were from PubMed, 3,233 from ScienceDirect, 3,075 from CINAHL, 588 from ProQuest, and 42 from Ovid MEDLINE. Three additional studies retrieved from ancestry reference lists of selected articles were included, and 14 duplicates were excluded. A total of 10,555 article titles and abstracts were reviewed to determine whether they met the inclusion criteria, and 10,417 articles were excluded because their foci did not match the necessary criteria. One hundred thirty-eight full-text articles were assessed for eligibility. After a closer examination of the articles, 110 publications were excluded because they were not related to HPV vaccination among African American mothers and their daughters. Twenty-eight publications were screened for eligibility and were included for the final synthesis (see Figure 1). Studies were appraised and evaluated for quality and level of evidence using the Johns Hopkins Research Evidence Appraisal Tool (see Table 1).
Characteristics of the Findings
The parents in this review were predominantly mothers aged 18–80 years and their daughters aged 9–26 years. The participants in three studies were only mothers (Cunningham-Erves et al., 2018; Strohl et al., 2015; Watkins et al., 2015). Two studies consisted of daughters only (Bynum et al., 2011; DiClemente et al., 2015), and four studies examined factors associated with both daughters and mothers in HPV vaccination uptake (Galbraith-Gyan et al., 2017; Hamlish et al., 2012; Hull et al., 2014; Joseph et al., 2016). Although seven publications examined parental beliefs and intention for HPV vaccination, the participants were predominantly mothers (Bryer, 2014; Fu et al., 2019; Galbraith-Gyan et al., 2018; Nan et al., 2016, 2019; Thompson et al., 2011, 2012). Participants in 12 studies had more than 20% African American females (Cipriano et al., 2018; Dixon et al., 2018; Fishman et al., 2014; Gelman et al., 2013; Gottlieb et al., 2009; Griffioen et al., 2012; Joseph et al., 2014; Nagpal et al., 2016; Perkins et al., 2010; Read et al., 2010; Rosenthal et al., 2008; Underwood et al., 2016).
Studies included were four randomized controlled trials (DiClemente et al., 2015; Dixon et al., 2018; Joseph et al., 2016; Underwood et al., 2016), 14 quantitative publications (Bryer, 2014; Bynum et al., 2011; Cipriano et al., 2018; Fishman et al., 2014; Fu et al., 2019; Gelman et al., 2013; Nagpal et al., 2016; Nan et al., 2016, 2019; Read et al., 2010; Rosenthal et al., 2008; Strohl et al., 2015; Thompson et al., 2011; Watkins et al., 2015), nine qualitative studies (Galbraith-Gyan et al., 2017, 2018; Gottlieb et al., 2009; Griffioen et al., 2012; Hamlish et al., 2012; Hull et al., 2014; Joseph et al., 2014; Perkins et al., 2010; Thompson et al., 2012), and one mixed study (Cunningham-Erves et al., 2018).
Factors Associated With HPV Vaccination of African American Mothers and Daughters
The factors identified in the review that affected HPV vaccination of African American mothers were summarized in five groups: approval and disapproval of HPV vaccination from physicians, family, and friends; HPV knowledge; attitudes and beliefs about HPV vaccination; benefits of vaccination; and challenges of and barriers to HPV vaccination.
Approval and Disapproval of HPV Vaccination From Physicians, Family, and Friends
African American mothers and daughters’ HPV vaccination decision was associated with approval or disapproval of healthcare providers, family, and friends. The majority of mothers trusted their healthcare providers to initiate the discussion of HPV vaccination (Hamlish et al., 2012). Mothers rely on HPV vaccination approval or disapproval from their daughters’ pediatrician. Physician recommendation was independently associated with HPV vaccination (Gottlieb et al., 2009), and most participants verbalized the likelihood of accepting HPV vaccination if offered by a physician (Joseph et al., 2014). The vaccination status of adolescents was significantly affected by whether a pediatrician had recommended the vaccine (p < 0.001) (Thompson et al., 2011). The majority of mothers indicated the influence of physician recommendation on HPV vaccination of their daughters (Thompson et al., 2012).
Source of information should be vital in HPV vaccination uptake. Most mothers rely on HPV vaccination information from the healthcare provider. The maternal source of information about HPV vaccine was associated with attitude, and attitude was associated with vaccine uptake among adolescents (Underwood et al., 2016). Low trust in health information from other sources, such as government health agencies, was associated with less favorable parental attitudes and intentions for HPV vaccination; however, trust in health information from physicians or healthcare providers did not predict vaccine acceptance (Nan et al., 2019).
The perceived social pressure from friends, family, and healthcare providers was also a significant predictor of maternal HPV vaccination intentions (p = 0.001) (Cunningham-Erves et al., 2018). Mothers trusted family members’ and friends’ advice regarding HPV vaccination. Perceived high exposure of mothers to anti–HPV vaccine viewpoints and low exposure to pro–HPV vaccine viewpoints were associated with HPV vaccine refusal (Fu et al., 2019). Negative information from media affects HPV vaccination acceptance (Galbraith-Gyan et al., 2017). Factors associated with HPV vaccination uptake among mothers included interactions with physicians, friends, family members, and media reports/marketing (Griffioen et al., 2012).
Knowledge about HPV and HPV vaccination was one of the factors associated with HPV vaccination uptake among African American mothers. A positive relationship existed between maternal attitude and knowledge about HPV (Cipriano et al., 2018). Most women with higher knowledge of HPV vaccination reported significantly higher HPV vaccination uptake (Bynum et al., 2011). Mothers with an increased understanding of HPV vaccinations were significantly (p = 0.04) more likely to complete the three-dose series earlier than those with low to moderate knowledge about HPV vaccinations (Nagpal et al., 2016). Mothers who received HPV vaccination educational interventions had a three-times-greater odd of receiving a dose of HPV vaccine (p = 0.003) (Dixon et al., 2018). Mothers reported limited information and lack of knowledge about the HPV vaccine as the reason for not initiating HPV vaccination (Gottlieb et al., 2009). Women who were younger, had a history of cancer, were less spiritual, and had higher education had better awareness of the HPV vaccine (Watkins et al., 2015). In addition, education level, household income, and having a child who had been offered HPV vaccination were associated with adequate knowledge about the HPV vaccine (Strohl et al., 2015).
However, in some studies, knowledge was not associated with adolescent vaccination (Fishman et al., 2014). In a study by Joseph et al. (2016), increase in knowledge scores postintervention was not associated with initiation and completion of vaccinations. Knowledge about the HPV vaccine alone did not necessarily lead to vaccinations (Thompson et al., 2011).
Attitudes and Beliefs About HPV Vaccination
Positive and negative attitudes influence mothers’ HPV vaccination of their adolescent daughters. Positive attitudes toward HPV vaccination were related to cancer prevention benefit and protection against infectious disease (Galbraith-Gyan et al., 2017). There was a relationship between vaccine behavioral beliefs and HPV attitudes, and attitude was related to vaccination intention (Bryer, 2014). The intention to vaccinate daughters against HPV correlates with vaccine uptake (Perkins et al., 2010). The factors influencing mothers’ decisions to vaccinate their daughters are beliefs and experiences (Griffioen et al., 2012). Mothers who believed that they were at risk for getting HPV infection and at risk for developing cervical cancer were more likely to get the HPV vaccine (DiClemente et al., 2015). The mother’s opinion about getting HPV infection was a significant predictor of maternal HPV vaccination intention (p = 0.044) (Cunningham-Erves et al., 2018). A study by Galbraith-Gyan et al. (2018) noted that both mothers and daughters perceived low risk of getting HPV infection, and mothers believed in their ability to decide on HPV vaccination for their daughters. Mothers with a high school diploma or lower and history of a sexually transmitted disease were more likely to accept HPV vaccination if their daughters were willing to receive three doses of HPV vaccination (Rosenthal et al., 2008).
Mothers with negative attitudes believed that the HPV vaccine was too new, their daughters were too young, and that the vaccine was not a one-size-fits-all intervention (Galbraith-Gyan et al., 2017). The mothers’ reasons for not initiating the HPV vaccine included the following: the daughter was too young, the daughter was not yet sexually active, and the daughter had not been to a physician yet (Gottlieb et al., 2009). Mothers anticipated their daughters’ sexual debut because of HPV vaccination and advocated for healthcare provider intervention to protect them (Hamlish et al., 2012). There have been discussions regarding religious belief and HPV vaccination uptake. Studies by Galbraith-Gyan et al. (2017) and Thompson et al. (2012) noted that religious doctrine did not hinder vaccination decisions among African American mothers.
Benefits of Vaccination
Understanding the benefits of HPV vaccination is vital in the uptake of the vaccine. HPV vaccination education offered to undecided mothers and daughters should be focused on the vaccine as cancer prevention (Hull et al., 2014). In the study by Galbraith-Gyan et al. (2018), mothers and daughters perceived that the HPV vaccine was beneficial against genital warts and cervical cancer. Mothers with cervical dysplasia or cancer were strongly motivated to vaccinate their daughters (Hamlish et al., 2012). Most mothers focused on the potential for cancer prevention when making the decision about HPV vaccination of their daughters (Perkins et al., 2010). A daughter’s knowledge about HPV vaccination and its association with cervical cancer prevention was significantly related to her interest in accepting the HPV vaccine (p < 0.001) (Read et al., 2010). Mothers responded more positively to the benefit of HPV vaccination as cancer prevention (Nan et al., 2016). Limited knowledge about the connection of HPV to cancer reduces the medical benefits of the vaccine (Hamlish et al., 2012).
Challenges of and Barriers to HPV Vaccination
Perceived barriers, such as limited knowledge, daughters’ age, and mistrust of pharmaceutical companies and physicians, affect maternal HPV vaccination intention (p < 0.001) (Cunningham-Erves et al., 2018). Barriers among mothers and daughters included policies and politics related to HPV vaccination, unknown side effects, and the safety of the HPV vaccine (Galbraith-Gyan et al., 2018). Attitude and social environmental factors, such as cost of vaccination, lack of insurance, and fear of early sexual activity, affected HPV vaccination uptake among African American mothers (Thompson et al., 2012). There were significant ethical and racial disparities related to HPV vaccination; African American individuals are less likely to initiate HPV vaccination than White individuals (p < 0.001) (Gelman et al., 2013).
The synthesis of the literature review findings was guided by the HBM to better understand the factors associated with HPV vaccination among African American mothers and their daughters. The HBM was developed to identify primary preventive behaviors related to vaccinations and explore the determinants of health-related behaviors pertaining to vaccinating a child (Rosenstock et al., 1988). Four HBM items were associated with four of the categories identified in the Results section, and they include the following: cues to action, perceived susceptibility, perceived benefit, and perceived barrier.
Cues to Action
Cues to action refer to the strategies to activate vaccination readiness through information from healthcare providers, media, friends, and relatives. Among the factors affecting HPV vaccination, the approval of vaccination from a healthcare provider was the most frequently identified factor in HPV vaccination intentions.
Healthcare provider recommendation was significantly associated with HPV vaccination intentions and uptake among African American mothers and daughters. Seven articles (Gottlieb et al., 2009; Hamlish et al., 2012; Joseph et al., 2014; Nan et al., 2019; Thompson et al., 2011, 2012; Underwood et al., 2016) explored the influence of a healthcare provider recommendation on HPV vaccination acceptance and uptake. A study by Hamlish et al. (2012) was performed to identify motivations and barriers to HPV vaccination and meaningful opportunity for vaccine promotion among African American mothers and daughters. The findings noted that mothers trusted healthcare providers to initiate a discussion about HPV vaccination. There is an association between HPV vaccination and physicians’ recommendations. Most mothers would accept HPV vaccination for their daughters if a healthcare provider recommended the vaccine (Gottlieb et al., 2009; Joseph et al., 2014; Thompson et al., 2012). The daughter’s vaccination status was significantly associated with physician recommendation (p < 0.001) (Thompson et al., 2011). Distributing health information related to HPV vaccination in the pediatrician’s office is essential because mothers’ source of information about HPV was associated with attitude and vaccine uptake (Underwood et al., 2016). Although mothers trusted health information from physicians and healthcare providers, receiving HPV information does not predict vaccine acceptance (Nan et al., 2019). Future studies will be needed to identify reasons related to unfavorable attitudes toward information from government health agencies.
Maternal strategy to activate readiness for HPV vaccination depends on interaction with friends and relatives. Mothers consider the viewpoint of their friends and relatives as it relates to immunization. Being around other mothers who were against HPV vaccination was associated with vaccine refusal (Fu et al., 2019). In addition, negative information from the media (Galbraith-Gyan et al., 2017), physicians, friends, and family members, including exposure to media reports and marketing, affects HPV vaccination acceptance (Griffioen et al., 2012). Interventions to improve HPV vaccination should include strategies to connect pro-vaccination mothers with mothers who have not decided to vaccinate their adolescent daughters against HPV.
The maternal decision for HPV vaccination was associated with perceived susceptibility, which means one’s opinion about getting HPV infection. If mothers believe their daughters can get HPV infection and cancer, their HPV vaccination intention will be favorable. Most of the studies reviewed indicated that positive beliefs and attitudes toward HPV vaccination intentions increased vaccine acceptance, and negative attitudes increased vaccine refusal. Bryer (2014) examined the determinants of African American mothers’ intentions to vaccinate their daughters against HPV. The findings indicated a significant relationship between HPV vaccine behavioral beliefs and HPV vaccine attitudes among African American mothers (r = 0.239, p < 0.001); mothers’ attitudes were significantly related to vaccine intentions (r = 0.865, p < 0.001). The intention to vaccinate daughters correlates with vaccine uptake (Perkins et al., 2010). Identifying factors influencing African American mothers’ decisions to vaccinate is essential in developing strategies to promote HPV vaccination uptake. Mothers’ decisions to vaccinate were based on their beliefs and experiences (Griffioen et al., 2012). The positive attitude toward HPV vaccination was related to the vaccine’s benefit in preventing infections and cancer (Galbraith-Gyan et al., 2017). A study by Cunningham-Erves et al. (2018) to investigate psychological and cultural factors associated with mothers’ intentions to vaccinate their daughters against HPV noted that mothers’ perceived risk of developing HPV infections was a significant predictor of maternal HPV vaccination intentions (p = 0.044). There is a significant need for educational interventions that focus on presenting the HPV vaccine as a cancer prevention vaccination. Mothers who believe that they are at risk for getting HPV and developing cervical cancer are more likely to get the HPV vaccine (DiClemente et al., 2015).
Negative attitudes and beliefs affect both mothers’ and daughters’ HPV vaccination intentions. A study by Gottlieb et al. (2009) to assess HPV vaccination of adolescent girls living in areas with elevated cervical cancer rates identified the mothers’ reason for not initiating HPV vaccination as the belief that the daughter was too young and not yet sexually active. Therefore, there is a need for educational interventions about HPV and HPV vaccination, focusing on the need for vaccinating daughters at an early age before they initiate sexual activity. Although mothers anticipate the sexual debut of their daughters because of HPV vaccination (Hamlish et al., 2012), the decision about HPV vaccination was not related to their sexual values or daughters’ sexual behavior (Rosenthal et al., 2008). Educational interventions to improve HPV vaccination uptake should include the effectiveness and safety of the vaccine 14 years after its inception.
To address maternal concerns about daughters’ sexuality and age of vaccination, educational interventions for African American mothers should emphasize the point that there was no relationship between HPV vaccination and an increase in sexual activities (Madhivanan et al., 2016). Creating awareness of the importance of vaccinating children early, at age 9 years, to prevent HPV infection before they start exposure to sexual activities would be ideal (CDC, 2019) to address parental concerns about the age of vaccination. This is like suggesting vaccination of children against measles and chickenpox before exposure to the disease. Much has been said regarding the impact of religious belief on HPV vaccination (Thompson et al., 2012); however, African American mothers and daughters stated that religion would not interfere with their vaccination decisions (Galbraith-Gyan et al., 2017; Thompson et al., 2012).
The benefits and challenges of HPV vaccination influence African American mothers’ decisions on HPV vaccination. Based on the HBM concept, the perceived benefit of vaccination is one’s belief of the vaccine’s efficacy to reduce the risk of cancer, and the perceived barrier is one’s opinion of the cost, access, transportation, and self-efficacy related to HPV vaccination. The HBM claims that if individuals believe they have the risk of getting an infection, they will more likely conclude that the benefits outweigh the barriers associated with behavior change to prevent the health issue (Rosenstock et al., 1988).
The review identified the relationship between the benefit of HPV vaccination as a cancer prevention vaccine and vaccination intent and uptake. Mothers with cervical dysplasia or cancer of the cervix were motivated to participate in cancer prevention activities for their children and had a strong commitment to vaccinate their daughters (Hamlish et al., 2012). The benefit of the HPV vaccine was related to cancer prevention. In a study by Read et al. (2010), about 55.8% of daughters’ knowledge of HPV vaccination and its association with cervical cancer prevention was significantly related to interest in accepting the HPV vaccine (p < 0.001); most mothers wanted the vaccine for its role in preventing cancer (Read et al., 2010; Perkins et al., 2010). HPV vaccination discussion with mothers who have not decided to accept HPV vaccination should focus on cancer prevention (Hull et al., 2014). Intervention studies to increase HPV vaccination should include emphasis on the benefit of HPV vaccine in cancer prevention because limited knowledge of HPV’s connection to cancer reduces the vaccine’s medical benefits (Hamlish et al., 2012).
Barriers identified by both mothers and daughters related to HPV vaccination include unknown side effects, safety, and effectiveness (Galbraith-Gyan et al., 2018). In a qualitative study by Thompson et al. (2012), using a structured interview to describe attitudes and social environmental factors that affect African American mothers’ intent to vaccinate their daughters against HPV identified barriers to HPV vaccination as the cost of immunization, lack of insurance, and fear of early sexual activity. Immunization cost and lack of insurance can be addressed by referral of eligible mothers to the Vaccines for Children Program. This federally funded program provides vaccines at no cost to low-income families (CDC, 2019). Mothers identified limited knowledge, daughter’s age, and mistrust of pharmaceutical companies and physicians as factors affecting maternal HPV vaccination intention (p < 0.001) (Cunningham-Erves et al., 2018). Another barrier to HPV vaccination among African American daughters was ethical and racial disparities. There were significant ethical and racial disparities in HPV vaccination among this population. African American individuals were less likely to initiate HPV vaccination than White individuals (p < 0.001) (Gelman et al., 2013).
Among the factors affecting HPV vaccination among African American mothers is inadequate knowledge about HPV and HPV vaccination. Having sufficient knowledge about HPV vaccination was associated with HPV vaccination intentions and uptake. A study by Bynum et al. (2011) assessed factors associated with HPV vaccine uptake among young African American women. The findings reported significantly higher knowledge among women with HPV vaccine acceptance (p < 0.05). The completion of the HPV vaccination series was essential in protecting daughters against HPV infection and HPV-related cancers. Most mothers with higher knowledge of HPV vaccine are three times more likely to accept a dose of the HPV vaccine (Dixon et al., 2018) and significantly more likely to complete the three-dose series of HPV vaccination (Nagpal et al., 2016). HPV vaccine knowledge was associated with higher education level, history of cancer, younger mothers (Watkins et al., 2015), higher household income, and having a child who has been offered HPV vaccination (Strohl et al., 2015). Mothers’ attitude was associated with HPV vaccine knowledge. A study by Cipriano et al. (2018) to evaluate parental attitude toward general vaccination protocol and increase knowledge about the HPV vaccine indicated that a moderate positive relationship existed between parental attitude and knowledge about HPV (r = 0.552, p < 0.001).
There were some studies in which knowledge about HPV vaccination was not positively related to vaccination acceptance and uptake. A randomized controlled pilot study by Joseph et al. (2016) to examine facilitators of and barriers to HPV vaccine uptake among African American mothers and daughters reported that increased knowledge score postintervention was not significantly associated with the initiation and completion of the HPV vaccine. Having adequate knowledge about HPV and the HPV vaccine alone did not necessarily lead to HPV vaccination uptake among African American individuals (Thompson et al., 2011). In addition, previous knowledge of mothers and their daughters was not associated with HPV vaccination prediction (Fishman et al., 2014). More research studies are needed to examine the educational interventions and their relationship with intentions to vaccinate.
Implications for Practice
Understanding factors related to HPV vaccination decisions among African American mothers will inform healthcare providers and researchers of the best approach to improving vaccination rates among this high-risk population. In all of the studies reviewed, major factors associated with HPV vaccination were depicted. Attitudes and beliefs were among the significant factors associated with maternal decisions to vaccinate daughters. Addressing African American mothers’ attitudes and beliefs toward HPV vaccination may be challenging. Nurses should play a significant role in providing HPV and HPV vaccination education that focuses on the HPV vaccine as a cancer prevention vaccination. Because mothers rely on healthcare provider information and recommendations, nurses should minimize missed opportunities in pediatric clinics and offer HPV vaccination information, including flyers, to mothers during clinic visits. In collaboration with other interprofessional teams, nurses can design and provide HPV vaccination interventions that can further assess the implications of the factors identified in this review. They can also design strategies to improve HPV vaccination uptake among this high-risk population.
The level of evidence and quality rating was limited because there were only four randomized controlled trials. The rest of the articles were qualitative and quantitative, with one mixed-methods study. Most studies had a small sample size and convenience samples, indicating a need for more clinical trials in this underrepresented population. There were a limited number of HPV-related studies designed for only African American mothers. Twelve studies were done with other racial groups, with more than 20% African American participants. These combinations may not depict the specific perception of factors affecting African American mothers regarding vaccinating their daughters. The findings were limited to articles obtained since the last search date; additional factors may have emerged from recent studies. The search was limited to HPV vaccination alone, and the factors affecting vaccination of adolescents, in general, may be missing.
The articles synthesized depict factors associated with HPV vaccination among African American mothers and daughters, including approval and disapproval of HPV vaccination from physicians, family, and friends; HPV knowledge; attitudes and beliefs about HPV vaccination; benefits of vaccination; and challenges of and barriers to HPV vaccination. Among the factors identified, attitudes and beliefs about HPV vaccination played a significant role in mothers’ decision to vaccinate their daughters. Although mothers decide based on the approval of friends and relatives, healthcare provider recommendation was the most significant predictor for intention to vaccinate against HPV. Knowledge about the HPV vaccine and the benefit of HPV vaccination in cancer prevention was strongly associated with vaccine intentions and uptake. The factors identified in the review could inform interventions that may improve vaccination uptake and decrease barriers to HPV vaccination among this high-risk population. Future research is needed to design more quantitative and randomized controlled trials to depict more factors affecting African American mothers’ perception of HPV vaccination. Strategies should be included to improve positive attitudes and beliefs regarding HPV vaccination among this high-risk population.
About the Author(s)
Stella Ngozi Dike, MSN, RN, OCN®, is a nurse educator and doctoral student and Wyona M. Freysteinson, PhD, MN, is a professor, both in the Nelda C. Stark College of Nursing at Texas Woman’s University in Houston. No financial relationships to disclose. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Society. Dike contributed to the conceptualization and design and completed the data collection. Freysteinson provided statistical support and the analysis. Both authors contributed to the manuscript preparation. Dike can be reached at email@example.com, with copy to ONFEditor@ons.org. (Submitted December 2020. Accepted February 24, 2021.)
American Cancer Society. (2019). Cancer facts and figures for African Americans 2019–2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-...
American Cancer Society. (2020). Risk factors for cervical cancer. https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/ri...
Bryer, J. (2014). Black parents’ beliefs, attitudes, and HPV vaccine intentions. Clinical Nursing Research, 23(4), 369–383. https://doi.org/10.1177/1054773813487749
Bynum, S.A., Brandt, H.M., Sharpe, P.A., Williams, M.S., & Kerr, J.C. (2011). Working to close the gap: Identifying predictors of HPV vaccine uptake among young African American women. Journal of Health Care for the Poor and Underserved, 22(2), 549–561. https://doi.org/10.1353/hpu.2011.0060
Centers for Disease Control and Prevention. (2019). Vaccine information statements. HPV (human papillomavirus) vaccine: What you need to know. U.S. Department of Health and Human Services. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv.html
Centers for Disease Control and Prevention. (2020). Human papillomavirus (HPV) vaccine: Safety information. https://www.cdc.gov/vaccinesafety/vaccines/hpv-vaccine.html.
Cipriano, J.J., Scoloveno, R., & Kelly, A. (2018). Increasing parental knowledge related to the human papillomavirus (HPV) vaccine. Journal of Pediatric Health Care, 32(1), 29–35. https://doi.org/10.1016/j.pedhc.2017.06.006
Cunningham-Erves, J., Forbes, L., Ivankova, N., Mayo-Gamble, T., Kelly-Taylor, K., & Deakings, J. (2018). Black mother’s intention to vaccinate daughters against HPV: A mixed methods approach to identify opportunities for targeted communication. Gynecologic Oncology, 149(3), 506–512. https://doi.org/10.1016/j.ygyno.2018.03.047
DiClemente, R.J., Murray, C.C., Graham, T., & Still, J. (2015). Overcoming barriers to HPV vaccination: A randomized clinical trial of a culturally-tailored, media intervention among African American girls. Human Vaccines and Immunotherapeutics, 11(12), 2883–2894. https://doi.org/10.1080/21645515.2015.1070996
Dixon, B.E., Zimet, G.D., Xiao, S., Tu, W., Lindsay, B., Church, A., & Downs, S.M. (2018). An educational intervention to improve HPV vaccination: A cluster randomized trial. Pediatrics, 143(1), e20181457. https://doi.org/10.1542/peds.2018-1457
Elam-Evans, L.D., Yankey, D., Singleton, J.A., Sterrett, N., Markowitz, L.E., Williams, C.L., . . . Stokey, S. (2020). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2019. Morbidity and Mortality Weekly Report, 69(33), 1109–1116. https://doi.org/10.15585/mmwr.mm6933a1
Everet, J.E., Marks, L.D., & Clarke-Mitchell, J.F. (2016). A qualitative study of the Black mother-daughter relationship. Journal of Black Studies, 47(4), 334–350. https://doi.org/10.1177/0021934716629339
Fishman, J., Taylor, L., Kooker, P., & Frank, I. (2014). Parent and adolescent knowledge of HPV and subsequent vaccination. Pediatrics, 134(4), e1049–e1056. http://doi.org/10.1542/peds.2013-3454
Fu, L.Y., Zimet, G.D., Latkin, C.A., & Joseph, J.G. (2019). Social networks for human papillomavirus vaccine advice among African American parents. Journal of Adolescent Health, 65(1), 124–129. https://doi.org/10.1016/j.jadohealth.2019.01.029
Galbraith-Gyan, K.V., Lechuga, J., Jenerette, C.M., Palmer, M.H., Moore, A.D., & Hamilton, J.B. (2017). HPV vaccine acceptance among African-American mothers and their daughters: An inquiry grounded in culture. Ethnicity and Health, 24(3), 323–340. https://doi.org/10.1080/13557858.2017.1332758
Galbraith-Gyan, K.V., Lechuga, J., Jenerette, C.M., Palmer, M.H., Moore, A.D., & Hamilton, J.B. (2018). African-American parents’ and daughters’ beliefs about HPV infection and the HPV vaccine. Public Health Nursing, 36(2), 134–143. https://doi.org/10.1111/phn.12565
Gelman, A., Miller, E., Schwarz, E.B., Akers, A.Y., Jeong, K., & Borrero, S. (2013). Racial disparities in human papillomavirus vaccination: Does access matter? Journal of Adolescent Health, 53(6), 756–762. https://doi.org/10.1016/j.jadohealth.2013.07.002
Gottlieb, S.L., Brewer, N.T., Sternberg, M.R., Smith, J.S., Ziarnowski, K., Liddon, N., & Markowitz, L.E., (2009). Human papillomavirus vaccine initiation in an area with elevated rates of cervical cancer. Journal of Adolescent Health, 45(5), 430–437. https://doi.org/10.1016/j.jadohealth.2009.03.029
Griffioen, A.M., Glynn, S., Mullins, T.K., Zimet, G.D., Rosenthal, S.L., Fortenberry, J.D., & Kahn, J.A. (2012). Perspectives on decision making about human papillomavirus vaccination among 11- to 12-year-old girls and their mothers. Clinical Pediatrics, 51(6), 560–568. https://doi.org/10.1177/0009922812443732
Hall, M.T., Simms, K.T., Lew, J.B., Smith, M.A., Brotherton, J.M.L., & Saville, M. (2019). The projected timeframe until cervical cancer elimination in Australia: A modelling study. Lancet Public Health, 4(1), E19–E27. https://doi.org/10.1016/s2468-2667(18)30183-x
Hamlish, T., Clarke, L., & Alexander, K.A. (2012). Barriers to HPV immunization for African American adolescent females. Vaccine, 30(45), 6472–6476. https://doi.org/10.1016/j.vaccine.2012.07.085
Hull, P.C., Williams, E.A., Khabele, D., Dean, C., Bond, B., & Sanderson, M. (2014). HPV vaccine use among African American girls: Qualitative formative research using a participatory social marketing approach. Gynecologic Oncology, 132(Suppl. 1), S13–S20. https://doi.org/10.1016/j.ygyno.2014.01.046
Johns Hopkins Medicine. (2017). John Hopkins nursing evidence-based practice: Appendix C: Evidence level and quality guide. https://www.hopkinsmedicine.org/evidence-based-practice/_docs/appendix_c...
Joseph, N.P., Bernstein, J., Pelton, S., Belizaire, M., Goff, G., Horanieh, N., & Freund, K.M. (2016). Brief client-centered motivational and behavioral intervention to promote HPV vaccination in a hard-to-reach population. Clinical Pediatrics, 55(9), 851–859. https://doi.org/10.1177/0009922815616244
Joseph, N.P., Clark, J.A., Mercilus, G., Wilbur, M., Figaro, J., & Perkins, R. (2014). Racial and ethnic differences in HPV knowledge, attitudes, and vaccination rates among low-income African American, Haitian, Latina, and Caucasian young adult women. Journal of Pediatric and Adolescent Gynecology, 27(2), 83–92. https://doi.org/10.1016/j.jpag.2013.08.011
Madhivanan, P., Pierre-Victor, D., Mukherjee, S., Bhoite, P., Powell, B., Jean-Baptiste, N., . . . Krupp, K. (2016). Human papillomavirus vaccination and sexual disinhibition in females: A systematic review. American Journal of Preventive Medicine, 5(3), 373–383. https://doi.org/10.1016/j.amepre.2016.03.015
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLOS Medicine, 6(7), e1000097. https://org/10.1371/journal.pmed.1000097
Nagpal, J., Linares, L.O., Weiss, J., Schlecht, N.F., Shankar, V., Braun-Courville, D., . . . Diaz, A. (2016). Knowledge about human papillomavirus and time to complete vaccination among vulnerable female youth. Journal of Pediatrics, 171, 122–127. https://doi.org/10.1016/j.jpeds.2015.12.070
Nan, X., Daily, K., Richards, A., Holt, C., Wang, M.Q., Tracy, K., & Qin, Y. (2019). The role of trust in health information from medical authorities in accepting the HPV vaccine among African American parents. Human Vaccines and Immunotherapeutics, 15(7–8), 1723–1731. https://doi.org/10.1080/21645515.2018.1540825
Nan, X., Madden, K., Richards, A., Holt, C., Wang, M.Q., & Tracy, K. (2016). Message framing, perceived susceptibility, and intentions to vaccinate children against HPV among African American parents. Health Communication, 31(7), 798–805. https://doi.org/10.1080/10410236.2015.1005280
Perkins, R.B., Pierre-Joseph, N., Marquez, C., Iloka, S., & Clark, J.A. (2010). Why do low-income minority parents choose human papillomavirus vaccination for their daughters? Journal of Pediatrics, 157(4), 617–622. https://doi.org/10.1016/j.jpeds.2010.04.013
Read, D.S., Joseph, M.A., Polishchuk, V., & Suss, A.L. (2010). Attitudes and perceptions of the HPV vaccine in Caribbean and African American adolescent girls and their parents. Journal of Pediatric and Adolescent Gynecology, 23(4), 242–245. https://doi.org/10.1016/j.jpag.2010.02.002
Rosenstock, I.M., Strecher, V.J., & Becker, M.H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15(2), 175–183. https://doi.org/10.1177/109019818801500203
Rosenthal, S.L., Rupp, R., Zimet, G.D., Meza, H.M., Loza, M.L., Short, M.B., & Succop, P.A. (2008). Uptake of HPV vaccine: Demographics, sexual history and values, parenting style, and vaccine attitudes. Journal of Adolescent Health, 43(3), 239–245. https://doi.org/10.1016/j.jadohealth.2008.06.009
Strohl, A.E., Mendoza, G., Ghant, M.S., Cameron, K.A., Simon, M.A., Schink, J.C., & Marsh, E.E. (2015). Barriers to prevention: Knowledge of HPV, cervical cancer, and HPV vaccinations among African American women. American Journal of Obstetrics and Gynecology, 212(1), 65.e1–65.e5. https://doi.org/10.1016/j.ajog.2014.06.059
Thompson, V.L.S., Arnold, L.D., & Notaro, S.R. (2011). African American parents’ attitudes toward HPV vaccination. Ethnicity and Disease, 21(3), 335–341. https://www.ncbi.nlm.nih.gov/pubmed/21942167
Thompson, V.L.S., Arnold, L.D., & Notaro, S.R. (2012). African American parents’ HPV vaccination intent and concerns. Journal of Health Care for the Poor and Underserved, 23(1), 290–301. https://doi.org/10.1353/hpu.2012.0007
Townsend, J.S., Steele, C.B., Hayes, N., Bhatt, A., & Moore, A.R. (2017). Human papillomavirus vaccine as an anticancer vaccine: Collaborative efforts to promote human papillomavirus vaccine in the national comprehensive cancer control program. Journal of Women’s Health, 26(3), 200–206. https://doi.org/10.1089/jwh.2017.6351
Underwood, N.L., Gargano, L.M., Jacobs, S., Seib, K., Morfaw, C., Murray, D., . . . Sales, J.M. (2016). Influence of sources of information and parental attitudes on human papillomavirus vaccine uptake among adolescents. Journal of Pediatric and Adolescent Gynecology, 29(6), 617–622. https://doi.org/10.1016/j.jpag.2016.05.003
U.S. Food and Drug Administration. (2019). Cervarix. https://www.fda.gov/vaccines-blood-biologics/vaccines/cervarix
Watkins, K.L., Reitzel, L.R., Wetter, D.W., & McNeill, L.H. (2015). HPV awareness, knowledge and attitudes among older African American women. American Journal of Health Behavior, 39(2), 205–211. https//doi.org/10.5993/AJHB.39.2.7
Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x
Williams, W.W., Lu, P.J., O’Halloran, A., Kim, D.K., Grohskopf, L.A., Pilishvili, T., . . . Rodriguez-Lainz, A. (2017). Surveillance of vaccination coverage among adult populations—United States, 2015. Morbidity and Mortality Weekly Report, 66(11), 1–28. https://doi.org/10.15585/mmwr.ss6611a1