HPV vaccine use among African American girls: Qualitative formative research using a participatory social marketing approach

Highlights

• Skeptical mothers need in-depth information about vaccine safety and age recommendations to accept the vaccine.

• Mothers suggested promoting HPV vaccine together with other pre-teen vaccines, targeting both boys and girls, and emphasizing cancer prevention.

• Findings suggest need to “normalize” perception of HPV vaccine as a routine vaccine rather than singling it out as unique.

Abstract

Objective

To generate recommendations for framing messages to promote HPV vaccination, specifically for African American adolescents and their parents who have not yet made a decision about the vaccine (the “Undecided” market segment).

Methods

Focus groups and interviews were conducted with African American girls ages 11–18 (N = 34) and their mothers (N = 31), broken into market segments based on daughter's vaccination status and mother's intent to vaccinate.

Results

Findings suggested that the HPV vaccine should be presented to “Undecided” mothers and adolescents as a routine vaccine (just like other vaccines) that helps prevent cancer. Within the “Undecided” segment, we identified two sub-segments based on barriers to HPV vaccination and degree of reluctance. The “Undecided/Ready If Offered” segment would easily accept HPV vaccine if given the opportunity, with basic information and a healthcare provider recommendation. The “Undecided/Skeptical” segment would need more in-depth information to allay concerns about vaccine safety, mistrust of drug companies, and recommended age. Some mothers and girls had the erroneous perception that girls do not need the vaccine until they become sexually active. African American adolescents and their mothers overwhelmingly thought campaigns should target both girls and boys for HPV vaccination. In addition, campaigns and messages may need to be tailored for pre-teens (ages 9–12) versus teens (ages 13–18) and their parents.

Conclusions

Findings pointed to the need to “normalize” the perception of HPV vaccine as just another routine vaccine (e.g., part of pre-teen vaccine package). Findings can inform social marketing campaigns targeting Undecided or ethnically diverse families.

Introduction

African American women have higher rates of cervical cancer incidence and mortality than white women, despite widespread cervical cancer screening in the United States [1], [2], [3]. In 2010, the age-adjusted incidence of cervical cancer was 6.5/100,000 for white women compared to 8.1/100,000 for African American women. Mortality rates (per 100,000 women) were 2.1 and 3.9, and overall 5-year survival for all stages of cervical cancer was 71% and 63% for white women and African American women, respectively [2]. Persistent infection with genital human papillomavirus (HPV) types 16 and 18 causes 70% of cervical cancers [4] and 86–95% of HPV-associated cancers of the oropharynx, anus, vagina, vulva and penis [5], [6]. Since 2006, the FDA has approved two prophylactics for females to prevent infection with HPV-16/18, and in 2010, one of them was also approved for use in males. These vaccines are nearly 100% efficacious in preventing HPV-16/18 associated cervical, vaginal, and vulvar precancers in women and highly efficacious for preventing penile precancers in men [6], [7], [8]. Thus, HPV vaccination is an important strategy to lower mortality from cervical cancer and other HPV-associated cancers.

The Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices recommend routine HPV vaccination for females and, also since 2011, for males at 11 or 12 years of age, as well as “catch-up” vaccination of up to the age of 26 years (females) and 21 years (males) [9], [10]. HPV vaccine consists of three doses across six months and is available for free to all adolescents ages 9 through 18 under private insurance, Medicaid and/or the Vaccines for Children (VFC) program. As of 2011, 53.3% of girls and 8.3% of boys aged 13–17 years in the United States started the HPV vaccine series, while only 34.8% of girls and 1.8% of boys completed all three doses [11]. In addition, HPV vaccine-series completion was lower among African American girls than white girls, with 60.8% versus 74.8% completion among girls who started the series more than 6 months prior to the interview date (reliable completion data by race are not available for boys). Another study found that white adolescents were twice as likely to complete the vaccination schedule on time compared with their African American counterparts, and adolescents with private insurance were 31% more likely compared to those with public insurance [12].

According to Dissemination of Innovations Theory [13], new innovations (e.g., new vaccines) are typically adopted by and benefit socially advantaged groups more rapidly. In other words, over time, increases in full utilization of HPV vaccine and declines in cervical cancer incidence and mortality will likely be faster among white women compared to African American women, potentially widening disparities in cervical cancer. The challenge is to design behavioral interventions that encourage vaccination, in particular among groups with lower vaccine completion rates.

Bryant and colleagues [14] developed the innovative Community-Based Participatory Marketing (CBPM) model, which combines community-based participatory research (CBPR) approaches with social marketing theories and methods. CBPR involves forming collaborative community-academic partnerships for research aimed to identify community needs and develop and test interventions to improve these problems [15], [16]. Incorporating the knowledge and insights of members of the affected population in the research process offers the potential to develop more culturally appropriate and effective interventions to improve health outcomes and reduce disparities [17].

Social marketing borrows principles and strategies from traditional marketing used in the business sector to sell products and generate profits, and applies them to nonprofit programs aimed at changing knowledge, attitudes or behaviors as the “product” [18], [19], [20]. Social marketing uses exchange theory, which explains that individuals make decisions about behaviors by weighing perceived costs and benefits of their different options. In the social marketing process, analytic techniques are used to conceptually divide the population into distinct audiences, or market segments, that are more likely to respond to the intervention [21]. Formative research, or “audience research,” uses qualitative and/or quantitative methods to develop the social marketing intervention plan and refine market segmentation, with the aim of understanding people's aspirations, values, and fears of the target population as well as their perceptions of the benefits versus costs of the target behavior [22]. Social marketing is an effective approach for developing culturally-appropriate interventions since it focuses on specific target audiences and emphasizes the audience's perspective [23], [24].

The key components of social marketing are often called the “4 Ps.” The most important “P” in social marketing is Product, including the “actual product” (the target behavior — HPV vaccination) and the “core product” (the benefits of the vaccine that are attractive to the target population and may convince a person to get it). Often the “core product” includes perceived non-health benefits of the behavior, such as fulfilling social or emotional needs. Price refers to real and perceived costs or barriers to engaging in the target behavior from the consumers' perspective and strategies to lower these costs. Placement involves where the target audience makes decisions about getting HPV vaccine and ways to make the service more accessible and easier to obtain. Promotion includes designing and delivering persuasive messages to the target audience [18].

Our team is employing the CBPM process to develop a culturally-appropriate social marketing intervention aimed at increasing HPV vaccine utilization among African American adolescents. This article reports on the qualitative findings of our formative research phase, or “audience research.” The purpose of the study was to generate recommendations for framing messages to promote HPV vaccination for our target audience, specifically African American adolescents and their parents who have not yet made a decision about the vaccine (the “Undecided” market segment). Our primary research questions related to the 4 Ps were: [1] Product — What benefits to vaccination do Undecided parents and adolescents perceive? [2] Price — What barriers to initiating and completing vaccination exist for the Undecided segment, and how can they be overcome? [3] Placement — Where do parents and adolescents make decisions about HPV vaccination, and how can the vaccine be made more accessible and easier to complete? and [4] Promotion — What types of messages, information channels, and spokespersons may be effective for the Undecided segment? We included both parents and daughters in the study to understand how parents and daughters negotiate decisions regarding HPV vaccination, determine whether parents or daughters should be the primary or secondary audience, and identify appropriate messaging strategies for each one.