Table of Contents
Introduction
Data has shown that Human Papillomavirus (HPV) is the most common viral infection of the reproductive tract infecting most individuals at some point after becoming sexually active (World Health Organization, 2018, p. 2). HPV is also known to cause the majority cervical cancer cases worldwide (World Health Organization, 2018). However, HPV is preventable through early adolescent vaccination. The public health importance of vaccination against HPV is demonstrated with a Healthy People 2020 target of 80% of girls aged 13 to 15 receiving the vaccination series (Morales-Campos, Markham, Peskin, & Fernandez, 2013, p. 570). However, statistics indicate rates fall well short of this goal (Morales-Campos, Markham, Peskin, & Fernandez, 2013).
Disparities exist among racial and ethnic groups within the United States in regards to HPV infections, cervical cancer and HPV vaccination rates (Joseph, et al., 2014). Latinas are disproportionately affected by cervical cancer in comparison to their white counterparts and vaccination rates appear to be an area where improvement could make a significant impact on incidence and mortality (Joseph, Clark, Mercilus, Wilbur, Figaro & Perkins, 2014). This paper will examine the literature on the attitudes, beliefs and vaccination rates of the Latina population and examine what health behavior theory would be best suited for developing programming to tackle this public health issue.
Background of Health Issue
Cervical cancer represents the fourth most common cancer in women worldwide and claims more than 270,000 lives each year (World Health Organization, 2018). In the United States alone there are approximately 12,000 new cases of cervical cancer and 4000 deaths each year (Joseph, et al., 2014). The majority of cervical cancer cases are attributable to HPV, an extremely common sexually transmitted infection that most sexually active individuals will contract (World Health Organization, 2018). While most HPV infections resolve without treatment, several risk factors contribute to HPV persistence and cancer development including multiple sexual partners, age at time of loss of virginity, tobacco use, and immune suppression (World Health Organization, 2018).
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There are currently two commercially available vaccinations that provide immunity against the most common types of cancer causing HPV, Cervarix and Gardasil. The vaccines aim to reach adolescents, both males and females, prior to participation in sexual activity as vaccination does not treat an HPV infection (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). The World Health Organization “recommends vaccination for girls aged 9-13 years as this is the most cost-effective public health measure against cervical cancer” (World Health Organization, 2018, p. 4).
Current Centers for Disease Control and Prevention (CDC) recommendations suggest all children aged 11 or 12 years should receive a HPV vaccination series (National Cancer Institute, 2018). Despite guideline driven recommendations, the United States still has only 34% complete vaccination coverage (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). Healthy People 2020 targets 80% completion of girls aged 13 to 15 (Morales-Campos, Markham, Peskin, & Fernandez, 2013, p. 570). Approximately 70% completion is necessary to achieve herd immunity (Galbraith, Lechuga, Jenerette, Moore, Palmer, & Hamilton, 2016). Studies of the general population have indicated that factors related to “higher vaccine-related knowledge, having a healthcare provider as a source of information, and maintaining positive vaccine attitudes” are correlated to an increase in vaccination uptake (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014, p. 1902).
It has been noted in multiple studies that ethnic disparities exist in HPV vaccination complete rates, specifically Hispanic adolescent females (Gerand, Zapata, & Reyes, 2013, p.623). The prevalence of HPV infection is the Latina population is 44.2%, which is the second highest comparatively (Jeudin, Liveright, Carmen, & Perkins, 2014, p. 28). In comparison to white women, Latinas have a 53% higher incidence of cervical cancer and a 41% higher mortality rate (Joseph, et al., 2014). These statistics indicate the need for a targeted campaign aimed to increase completion of the HPV vaccination series in Latinas.
Current and previous programming has been focused on educational interventions with both adolescents and parents. Outcomes of studies on educational interventions have demonstrated that adolescent intentions to vaccinate can be amendable and positive attitudes towards the vaccination can be achieved, with similar results seen in their parents (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). However, intention and uptake do not have a high correlation and intention fades quickly post-intervention (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). In spite of previously mentioned disparities, few interventions have been targeted towards these populations (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014).
Targeted Population
The targeted population will be middle and high school aged (11-15 years) Latina females’ parents in Texas. Latina females nationwide represent 17% of the overall female population and have the second highest prevalence of HPV infection (Jeudin, Liveright, Carmen, & Perkins, 2014). Latinas have a 53% higher incidence of cervical cancer and a 41% higher mortality rate (Joseph, et al., 2014). Specifically, Latinas in Texas “have higher incidence and mortality rates of cervical cancer than women nationally” (Morales-Campos, Markham, Peskin, & Fernandez, 2013, p. 569).
Survey data of high school Latina girls highlights several key risk factors. Statistics show that 45.4% are sexually experienced, 3.7% had sexual intercourse before age 13 and 10.4% had four or more lifetime sexual partners (Morales-Campos, Markham, Peskin, & Fernandez, 2013, p. 569-570). These experiences align with risk factors for acquiring HPV, leading to increased risk for developing cervical cancer. Because the age of indication for the vaccination is that of minors and parental consent will be necessary, any targeted campaign messaging must be directed at the parental population. And while data shows adolescent Latinos are sexually active, it is important to note that the Latino population generally views discussion of sexuality within the family and community as taboo and therefore, cultural context will be important in any program planning (Galbraith, et al., 2016).
Integration of the Health Issue and Target Population
There have been multiple studies examining issues affecting HPV vaccination rates in the Hispanic and Latina community. In general, most Latino parents are receptive to the idea of an HPV vaccination (Galbraith, et al., 2016). A survey of literature by Galbraith, et al. found that acceptability of the vaccination was most closely correlated with a variety of factors including “the vaccine’s cancer preventative benefits, low perceived risk of negative side effects, believing that other parents are vaccinating their children (norms), positive attitudes towards vaccines in general, perceived risk of daughter’s acquiring HPV, acceptance of pre-marital sex, low worry that vaccination may encourage initiation of sexual relations, and receiving a provider’s recommendation” (Galbraith, et al., 2016, p. 122).
Jeudin, Liveright, Carmen, & Perkins found similar beliefs among parents, but also found that a prior personal experience with an HPV related disease was important in creating acceptance of the vaccine (Jeudin, Liveright, Carmen, & Perkins, 2013). Conversely, “mothers who perceived their daughters at low risk for contracting HPV, had insufficient knowledge about the vaccine and believed their daughters were too young or not sexually active were less likely to vaccinate” (Morales-Campos, Markham, Peskin, & Fernandez, 2013, p. 570). Additionally, some parents were concerned with vaccine safety or a lack of information (Jeudin, Liveright, Carmen, & Perkins, 2013).
When assessing the actual obtaining of the vaccination, additional predictors emerged. The importance of safety and effectiveness remained present, but other cultural factors such as the beliefs of the child’s father, sexually related communication between the mother and daughter and norms were important (Galbraith, et al., 2016). However, the strongest link to actual uptake of the vaccine was provider recommendation (Jeudin, Liveright, Carmen, & Perkins, 2013). In one study, no Latinas ever reported declining a recommended vaccine (Joseph, et al., 2014). However, Latina girls parents have reported lower rates of provider recommended HPV vaccination (Jeudin, Liveright, Carmen, & Perkins, 2013). This could be due to a variety of factors.
The Migrant Clinicians Network reports limited English proficiency and unfamiliarity with local health resources as two possible challenges (Migrant Clinicians Network, 2015). Jeudin et. al. found that parents with “higher levels of American acculturation were more likely to report provider recommendation” (Jeudin, Liveright, Carmen, & Perkins, 2013, p. 28). Furthermore, even if initiation of the vaccination series occurs Latina girls are significantly less likely to complete the series (Jeudin, Liveright, Carmen, & Perkins, 2013). Variables related to logistics appear to be the most responsible, including “finding the times and locations of clinics inconvenient and lack of clinic reminder/recall systems” (Jeudin, Liveright, Carmen, & Perkins, 2013, p. 29).
Selected Theory to Address Health Issue
Based upon the factors that have been elucidated affecting the initiation and completion of the HPV vaccination series in Latina girls, the Information-Motivation-Behavioral Skills Model (IMB) fits exceptionally well. The first construct of the theory suggests knowledge is a prerequisite to behavior change (DiClemente, Salazar & Crosby, 2013). This aligns with data suggesting higher level of knowledge among Latina mothers is directly associated with increased likelihood of vaccination (Morales-Campos, Markham, Peskin, & Fernandez, 2013).
The second construct of IMB, motivation, is a combination of seeking protection from a perceived threat and social influences (DiClemente, Salazar & Crosby, 2013). Many of the parents surveyed in studies regarding their attitudes towards HPV vaccination of their children indicated the importance of the vaccine’s cancer preventative benefits (Galbraith, et al., 2016). Additionally, parents noted that believing that other parents were vaccinating their children played a role as well (Galbraith, et al., 2016).
The final construct of the IMB model is behavioral skills, which includes perception based self-efficacy and task -specific ability (DiClemente, Salazar & Crosby, 2013, p. 76). This is of particular note when discussing programming in regards to vaccine uptake and not simply intention. The logistical issues such as scheduling, finding appropriate locations, and reliance upon reminder systems noted by Jeudin et al. indicate the need for self-efficacy based programming (Jeudin, Liveright, Carmen, & Perkins, 2013).
DiClemente, Salazar & Crosby note that the model allows for all three constructs independently to affect behavior (DiClemente, Salazar & Crosby, 2013). However, the constructs can also influence each other. The interplay of these three constructs will be extremely important in developing programming to address the low vaccine completion rates in Latinas. Parental knowledge, social norms, and provider recommendations all were extremely important in creating acceptance and intent to vaccinate their children. (Morales-Campos, Markham, Peskin, & Fernandez, 2013). Additionally, the strength of provider recommendation lead to initiation of the vaccine series (Galbraith, et al., 2016). However, self-efficacy and skills became a problem when completing the vaccination series (Jeudin, Liveright, Carmen, & Perkins, 2013). It is the interplay of the three constructs that makes this theory appropriate to found programming on.
Programming would need to include continued relevant education of parents to address vaccination safety and efficacy and cancer preventative benefits. Additionally, education would need to address some of the norms based barriers that surfaced, including the perception that the vaccination would give girls the permission to become sexually active.
Finally, to ensure that perceptions and knowledge were able to be translated into action it would be important to initiate a campaign designed at access to services. This could be targeted at parents and their ability to find provider locations, increasing hours of operations at clinics, and increasing the number of facilities outside of traditional physician’s offices. Additionally, any programming of this nature would be lacking if not also targeted at the providers and their ability to make the recommendation to the population and follow through with administration at each available opportunity.
Discussion of Conclusion and Recommendation
The Latina population in the United States is falling well short of the Healthy People 2020 goal of 80% immunization of girls aged 13-15 (Morales-Campos, Markham, Peskin, & Fernandez, 2013). The literature has demonstrated that Latinos have favorable views of vaccinations in general (Gerand, Zapata, & Reyes, 2013, p. 624). Reviews of studies have observed that the uptake of vaccines is correlated to “having high vaccine related knowledge, having a healthcare provider as a source of information and maintaining positive vaccine attitudes” (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014, p. 1902).
These correlations have carried over to the Latina population, particularly among parents of Latina girls eligible for HPV vaccination (Jeudin, Liveright, Carmen, & Perkins, 2013). Additionally, receiving a provider’s recommendation was highly correlated to receipt of the vaccination (Galbraith, et al., 2016). The intersection of knowledge, beliefs, and the practical factor of provider influence make this public health issue suited for a targeted intervention with IMB as its core.
Fernandez, Allen, Mistry and Kahn have outlined a framework that includes a three tiered approach that could easily be translated to the Latina population (Fernandez, Allen, Mistry & Kahn, 2010). The group suggests community educational interventions, provider education and organizational change, and vaccine access change through policy (Fernandez, Allen, Mistry & Kahn, 2010).
Crafting a program targeted at the Latina population after this model with IMB at its core could lead to increased vaccination completion rates and decreases in the cervical cancer incidence and mortality. Such a program would need to focus on education of the parental unit in regards to vaccination safety and efficacy, as well as address some of the behavioral concerns of parents regarding sexual activity of their adolescents. Additionally, the education would need to highlight the susceptibility of the population, and provide factual evidence and relatable context, as these were both factors correlated with increased intent to vaccinate.
As suggested by Fernandez et al. peer-led educational campaigns may be helpful due to the influence of cultural and social norms (Fernandez, Allen, Mistry & Kahn, 2010). Any educational materials should be tailored to the language and cultural norms. It should be noted, however, that previous us of Spanish language radio advertisements did not increase parental intention to vaccinate ((Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). However, one study has found possibility in the use of social network interventions (Galbraith, et. al., 2016).
Because of the strongly correlated factor of provider recommendation, it will be important that any campaign additionally educate providers on the importance of strong, timely recommendations. Vaccinations should be readily available for administration in the clinics and reminder systems should be in place to encourage follow-up and subsequent vaccination receipt. Other non-traditional providers such as pharmacists should also be educated on the importance of vaccination in this population and should be ready to provider the immunization within their state’s practice guidelines to prevent access to primary care becoming a barrier.
Finally, the issue must be tackled from a policy prospective. Often immigrant populations find difficulty accessing healthcare and navigating a new system (Wilson, Rubens-Augustson, Murphy, Jardine, Crowcroft, Hui & Wilson, 2018). Policy will need to be focused on access and affordability for underserved populations. This will undoubtedly be difficult given the current political climate, but public health efforts must focus on equitable access to the vaccination if achievement of the Healthy People 2020 goal is expected.
Understanding the problem from an attitude, behavior and practical perspective will allow a program to be crafted with the ability to create meaningful outcomes. Theoretical underpinnings that integrate all of these perspectives will create sustainable change that will lead to lasting benefits.
