515944 research-article2013 Pierre Joseph et al
CPJ53210.1177/0009922813515944Clinical PediatricsPierre Joseph et al.
Article
Ethnic Differences in Perceived Benefits and Barriers to HPV Vaccine Acceptance: A Qualitative Analysis of Young African American, Haitian, Caucasian, and Latino Men
Clinical Pediatrics 2014, Vol. 53(2) 177–185 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813515944 cpj.sagepub.com
Natalie Pierre Joseph, MD, MPH1, Myrdell Belizaire, BA1, Courtney L. Porter, MPH1, Jared P. Walsh, MA1, Michael Esang, MBBCh, MPH1, Ginette Goff, BS1, and Rebecca B. Perkins, MD, MSc2
Abstract Purpose: To examine the attitudes toward human papillomavirus (HPV) vaccination among young men from African American, Haitian, Caucasian, and Latino backgrounds. Methods: We used in-person surveys at an urban teaching hospital from 2010 to 2012 to examine the racial and ethnic differences in the perceived benefits and barriers to HPV vaccination and vaccine mandate acceptance among 18- to 22-year-old African American, Haitian, Caucasian, and Latino men. Results: A total of 89 men participated (35% African American, 29% Haitian, 20% Latino, and 16% white). Participants from all ethnic groups perceived benefits to HPV vaccination but differed in their perceptions of barriers to vaccination as well as their acceptance of a vaccine mandate. Conclusions: Culturally competent educational messages may overcome ethnic differences in the attitudes, beliefs, and behaviors regarding vaccination among college-aged men from an urban population. Keywords human papillomavirus, HPV vaccination, HPV-related cancer prevention, urban young adult heterosexual men, immigrant, Haitian, Latino, African American
Introduction The human papillomavirus (HPV) is a sexually transmitted disease (STD) that causes genital warts and cancers of the mouth, anus, and penis in men.1 Persistent HPV infection is responsible for approximately 36% of penile cancers, 93% of anal cancers, and more than 70% of oropharyngeal cancers in men.2,3 More than 12 000 HPV-associated cancers are diagnosed in men each year.3 An estimated 7000 cancers in men are associated with HPV-16 and 18, found in the quadrivalent HPV vaccine.1 Furthermore, the incidence of HPV-related cancer is disproportionately higher among low-income minority (African American and Latino) men compared with higher-income Caucasian men.3-8 In October 2011, the Advisory Committee on Immunization Practices (ACIP) approved a recommendation to administer the quadrivalent HPV vaccine to boys 11 to 21 years old, whereas men aged 22 to 26 may be vaccinated, approximately 5 years after the same
recommendation was approved for girls.1 However, public health initiatives to promote HPV vaccination have predominantly targeted women and the protection against cervical cancer; these initiatives have failed to adequately educate men who are equally susceptible to HPV infection.2 Initiation and completion of the 3-dose series of the HPV vaccine has remained low among adolescent girls aged 13 to 17 years (completion 32% in 2010).9 Initiation rates also suffer among adolescent women 19 to 26 years old who do not need parental permission to initiate the series (initiation rates of 29.5% in 2011 and 20.7% in 2010).10 The purpose of this study 1
Boston Medical Center, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA
2
Corresponding Author: Natalie Pierre Joseph, Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, 85 East Concord, Vose 4th Floor 418, Boston, MA 02118, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on March 29, 2015
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Clinical Pediatrics 53(2)
was to assess the attitudes, beliefs, and behaviors among young men 18 to 22 years old concerning HPV and HPV vaccination.
Methods To determine the factors that may influence HPV vaccine acceptance among young men, we adopted a mixedmethods approach in which we collected both quantitative and qualitative data. This article reports the qualitative data to compare the attitudes, beliefs, and behaviors toward HPV vaccination among different ethnic subgroups. We interviewed young men 18 to 22 years old who attended a clinic for preventive care or a problem-related visit between December 2010 and October 2011. They were recruited from pediatric and adolescent practices in an urban academic medical center and one community health center that serves Boston’s low-income, urban populations. Men who spoke English, Spanish, or Haitian Creole were eligible for inclusion in the study. Trained research assistants reviewed schedules to determine eligible patients and recruited young men in the waiting areas before scheduled visits. We targeted a diverse sample of black (which included African American, Haitian, and African individuals), Latino, and Caucasian young men. The semistructured interviews were conducted in English, Spanish, and HaitianCreole by native speakers; they were then transcribed in English as a common platform for coding. Qualitative questions were designed following recommendations from previous studies based on constructs of the Health Belief Model, which assesses participants’ perceived severity, perceived susceptibility, perceived benefits, and perceived barriers.11,12 Inquiries addressed beliefs held by adolescent men concerning their sexuality and HPV vaccination for men. The responses of each participant were probed for complexity and to encourage answers that reflected perceived severity, perceived susceptibility, perceived benefits, and perceived barriers to vaccination according to the Health Belief Model. Participants were also asked to explain, in an open-ended fashion, their own personal reasons for or against HPV vaccination for themselves. Interviews were audiorecorded and transcribed. Spanish/ Creole data were transcribed in the language used, translated to English by one bilingual investigator, and then reviewed by a second bilingual investigator to verify the accuracy of the translation. Participants received $15 gift cards for their participation. The Boston University Medical Center’s institutional review board approved this study. Qualitative data analysis was performed using grounded theory and content analysis methods.5 Interview
transcripts were closely read to identify meaningful content that expressed attitudes toward vaccination as well as the perceived susceptibility, severity, benefits, and barriers of HPV vaccination.6 Two investigators independently coded each transcript. Codes were reviewed with the group, and areas of disagreement were resolved through discussion. Common themes, issues, and language use were noted and placed into broader coding categories based on the similarity of content. The analysis included systematic comparisons within and between ethnic groups to infer significant themes and describe meaningful variation.
Results A total of 89 men participated (31 black, 26 Haitian, 18 Latino, and 14 Caucasian). The average age was 19 years (Table 1). We identified major barriers to vaccine acceptance among participants. Responses, which are listed in Table 2, were organized by ethnic group and categorized into perceived benefits to HPV vaccination, perceived barriers to HPV vaccination, attitudes toward male sexual behavior, attitudes toward gender differences in vaccination, and HPV vaccine mandate acceptance/rejection.
Perceived Benefits of HPV Vaccination The prevention of anal and oral cancer emerged as a benefit of vaccination across all ethnic groups. One Latino man, who engaged in safe-sex practices, viewed HPV vaccination as beneficial only in addition to safe sex: “Cuz I wanted to be protected from cancer.” Haitian men perceived protection from cancer as a sufficient reason for vaccination. The response of one Haitian man was more generalized to include “anything that can be done at the beginning to prevent cancer or to prevent anything that can be hurtful in a certain way.” One Caucasian man with a medical background cited protection from oral and anal cancers as a specific benefit of vaccination: “If there is evidence that proves that the vaccine is gonna help me . . . I don’t want to deal with anal or oral cancers and I just know the incidence of HPV in people my age. It’s extraordinarily high, so I think you do need to take a really preventative outlook, but I think it just makes sense if I have that information.” Participants viewed the promise of protection from an STD as another important benefit of vaccination, as illustrated by one Latino man: “I’m afraid of STDs. I get tested every 6 months and if I could earlier, I would.” One Caucasian man was willing to pay for the vaccine if needed: “If you can prevent a disease as nasty as this one from attacking you, then I don’t see why not—even if it
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on March 29, 2015
179
Pierre Joseph et al Table 1. HPV Vaccination Among Urban Young Men: Demographic Information by Racial/Ethnic Category. Variable Age (years), mean (SD) Age category 18-19 Years 20-22 Years Education Less than high school High school At least some college Marital status Single Married or in relationship Country of origin United States Haiti Other Language English Creole Spanish Practice religion Physician is primary source of information about vaccination How do you like info to be presented Talking with physician Written materials Internet High level of trust in physician Supports mandate Yes No Missing values Sexually active Yes No Missing values
Total, n = 89, n (%)
African American, n = 31, n (%)
Haitian, n = 26, n (%)
Latino, n = 18, n (%)
White, n = 14, n (%)
19.1 (1.3)
19.2 (1.4)
19.1 (1.1)
18.6 (1.1)
19.7 (1.4)
52 (58) 37 (42)
16 (52) 15 (48)
16 (62) 10 (39)
14 (78) 4 (22)
6 (43) 8 (57)
28 (32) 33 (37) 28 (32)
14 (45) 9 (29) 8 (26)
4 (15) 12 (46) 10 (39)
6 (33) 10 (56) 2 (11)
4 (29) 2 (14) 8 (57)
86 (97) 2(3)
30 (97) 1 (3)
25 (96) 1 (4)
17 (94) 1 (6)
14 (100) 0
69 (78) 10 (11) 10 (11)
31 (100) 0 0
16 (62) 10 (38) 0
10 (56) 0 8 (44.4)
12 (86) 0 2 (14)
80 (90) 5 (6) 4 (4) 48 (54) 82 (92)
31 (100) 0 0 10 (32) 27 (87)
21 (81) 5 (19) 0 18 (69) 25 (96)
14 (78) 0 4 (22) 13 (72) 18 (100)
14 (100) 0 0 7 (50) 12 (86)
80 (91) 26 (30) 18 (21) 76 (85)
26 (84) 12 (39) 12 (39) 22 (71)
24 (92) 9 (35) 4 (15) 24 (92)
17 (100) 3 (18) 1 (6) 17 (94)
13 (93) 2 (14) 1 (7) 13 (93)
53 (60) 30 (34) 6 (7)
17 (55) 10 (32) 4 (13)
15 (58) 11 (42) 0 (0)
13 (72) 4 (22) 1 (6)
8 (57) 5(36) 1 (7)
49 (55) 9 (10) 31 (35)
16 (52) 2 (6) 13 (42)
18 (69) 3 (12) 5 (19)
does cost to get the vaccine.” African American and Haitian men also favored the protective benefits of vaccination; one African American man perceived the vaccine as a way “to be protected and to be safe to decrease my chances of getting STDs.” Participants from all backgrounds viewed HPV vaccination as beneficial to their health as well as public health. One African American man reported that he vaccinated, “Cuz, I don’t know when I’m gonna have sex and I wanna be protected when I do so I don’t infect anybody else.” One Caucasian man said that vaccination “would be the prevention of an epidemic or, you know, just stopping the spread of disease.” Some participants believed that public health benefits outweighed potential vaccination risks: “Well, it doesn’t take much to vaccinate people, so I guess it is helpful. Just go and get a shot and you are all set.”
9 (50) 2 (11) 7 (38.9)
P Value (ANOVA, χ2 or Fisher’s Exact Test)
6 (43) 2 (14) 6 (43)
.10 .18
.02 .82
CPJ53210.1177/0009922813515944Clinical PediatricsPierre Joseph et al.
Article
Ethnic Differences in Perceived Benefits and Barriers to HPV Vaccine Acceptance: A Qualitative Analysis of Young African American, Haitian, Caucasian, and Latino Men
Clinical Pediatrics 2014, Vol. 53(2) 177–185 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813515944 cpj.sagepub.com
Natalie Pierre Joseph, MD, MPH1, Myrdell Belizaire, BA1, Courtney L. Porter, MPH1, Jared P. Walsh, MA1, Michael Esang, MBBCh, MPH1, Ginette Goff, BS1, and Rebecca B. Perkins, MD, MSc2
Abstract Purpose: To examine the attitudes toward human papillomavirus (HPV) vaccination among young men from African American, Haitian, Caucasian, and Latino backgrounds. Methods: We used in-person surveys at an urban teaching hospital from 2010 to 2012 to examine the racial and ethnic differences in the perceived benefits and barriers to HPV vaccination and vaccine mandate acceptance among 18- to 22-year-old African American, Haitian, Caucasian, and Latino men. Results: A total of 89 men participated (35% African American, 29% Haitian, 20% Latino, and 16% white). Participants from all ethnic groups perceived benefits to HPV vaccination but differed in their perceptions of barriers to vaccination as well as their acceptance of a vaccine mandate. Conclusions: Culturally competent educational messages may overcome ethnic differences in the attitudes, beliefs, and behaviors regarding vaccination among college-aged men from an urban population. Keywords human papillomavirus, HPV vaccination, HPV-related cancer prevention, urban young adult heterosexual men, immigrant, Haitian, Latino, African American
Introduction The human papillomavirus (HPV) is a sexually transmitted disease (STD) that causes genital warts and cancers of the mouth, anus, and penis in men.1 Persistent HPV infection is responsible for approximately 36% of penile cancers, 93% of anal cancers, and more than 70% of oropharyngeal cancers in men.2,3 More than 12 000 HPV-associated cancers are diagnosed in men each year.3 An estimated 7000 cancers in men are associated with HPV-16 and 18, found in the quadrivalent HPV vaccine.1 Furthermore, the incidence of HPV-related cancer is disproportionately higher among low-income minority (African American and Latino) men compared with higher-income Caucasian men.3-8 In October 2011, the Advisory Committee on Immunization Practices (ACIP) approved a recommendation to administer the quadrivalent HPV vaccine to boys 11 to 21 years old, whereas men aged 22 to 26 may be vaccinated, approximately 5 years after the same
recommendation was approved for girls.1 However, public health initiatives to promote HPV vaccination have predominantly targeted women and the protection against cervical cancer; these initiatives have failed to adequately educate men who are equally susceptible to HPV infection.2 Initiation and completion of the 3-dose series of the HPV vaccine has remained low among adolescent girls aged 13 to 17 years (completion 32% in 2010).9 Initiation rates also suffer among adolescent women 19 to 26 years old who do not need parental permission to initiate the series (initiation rates of 29.5% in 2011 and 20.7% in 2010).10 The purpose of this study 1
Boston Medical Center, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA
2
Corresponding Author: Natalie Pierre Joseph, Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, 85 East Concord, Vose 4th Floor 418, Boston, MA 02118, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on March 29, 2015
178
Clinical Pediatrics 53(2)
was to assess the attitudes, beliefs, and behaviors among young men 18 to 22 years old concerning HPV and HPV vaccination.
Methods To determine the factors that may influence HPV vaccine acceptance among young men, we adopted a mixedmethods approach in which we collected both quantitative and qualitative data. This article reports the qualitative data to compare the attitudes, beliefs, and behaviors toward HPV vaccination among different ethnic subgroups. We interviewed young men 18 to 22 years old who attended a clinic for preventive care or a problem-related visit between December 2010 and October 2011. They were recruited from pediatric and adolescent practices in an urban academic medical center and one community health center that serves Boston’s low-income, urban populations. Men who spoke English, Spanish, or Haitian Creole were eligible for inclusion in the study. Trained research assistants reviewed schedules to determine eligible patients and recruited young men in the waiting areas before scheduled visits. We targeted a diverse sample of black (which included African American, Haitian, and African individuals), Latino, and Caucasian young men. The semistructured interviews were conducted in English, Spanish, and HaitianCreole by native speakers; they were then transcribed in English as a common platform for coding. Qualitative questions were designed following recommendations from previous studies based on constructs of the Health Belief Model, which assesses participants’ perceived severity, perceived susceptibility, perceived benefits, and perceived barriers.11,12 Inquiries addressed beliefs held by adolescent men concerning their sexuality and HPV vaccination for men. The responses of each participant were probed for complexity and to encourage answers that reflected perceived severity, perceived susceptibility, perceived benefits, and perceived barriers to vaccination according to the Health Belief Model. Participants were also asked to explain, in an open-ended fashion, their own personal reasons for or against HPV vaccination for themselves. Interviews were audiorecorded and transcribed. Spanish/ Creole data were transcribed in the language used, translated to English by one bilingual investigator, and then reviewed by a second bilingual investigator to verify the accuracy of the translation. Participants received $15 gift cards for their participation. The Boston University Medical Center’s institutional review board approved this study. Qualitative data analysis was performed using grounded theory and content analysis methods.5 Interview
transcripts were closely read to identify meaningful content that expressed attitudes toward vaccination as well as the perceived susceptibility, severity, benefits, and barriers of HPV vaccination.6 Two investigators independently coded each transcript. Codes were reviewed with the group, and areas of disagreement were resolved through discussion. Common themes, issues, and language use were noted and placed into broader coding categories based on the similarity of content. The analysis included systematic comparisons within and between ethnic groups to infer significant themes and describe meaningful variation.
Results A total of 89 men participated (31 black, 26 Haitian, 18 Latino, and 14 Caucasian). The average age was 19 years (Table 1). We identified major barriers to vaccine acceptance among participants. Responses, which are listed in Table 2, were organized by ethnic group and categorized into perceived benefits to HPV vaccination, perceived barriers to HPV vaccination, attitudes toward male sexual behavior, attitudes toward gender differences in vaccination, and HPV vaccine mandate acceptance/rejection.
Perceived Benefits of HPV Vaccination The prevention of anal and oral cancer emerged as a benefit of vaccination across all ethnic groups. One Latino man, who engaged in safe-sex practices, viewed HPV vaccination as beneficial only in addition to safe sex: “Cuz I wanted to be protected from cancer.” Haitian men perceived protection from cancer as a sufficient reason for vaccination. The response of one Haitian man was more generalized to include “anything that can be done at the beginning to prevent cancer or to prevent anything that can be hurtful in a certain way.” One Caucasian man with a medical background cited protection from oral and anal cancers as a specific benefit of vaccination: “If there is evidence that proves that the vaccine is gonna help me . . . I don’t want to deal with anal or oral cancers and I just know the incidence of HPV in people my age. It’s extraordinarily high, so I think you do need to take a really preventative outlook, but I think it just makes sense if I have that information.” Participants viewed the promise of protection from an STD as another important benefit of vaccination, as illustrated by one Latino man: “I’m afraid of STDs. I get tested every 6 months and if I could earlier, I would.” One Caucasian man was willing to pay for the vaccine if needed: “If you can prevent a disease as nasty as this one from attacking you, then I don’t see why not—even if it
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on March 29, 2015
179
Pierre Joseph et al Table 1. HPV Vaccination Among Urban Young Men: Demographic Information by Racial/Ethnic Category. Variable Age (years), mean (SD) Age category 18-19 Years 20-22 Years Education Less than high school High school At least some college Marital status Single Married or in relationship Country of origin United States Haiti Other Language English Creole Spanish Practice religion Physician is primary source of information about vaccination How do you like info to be presented Talking with physician Written materials Internet High level of trust in physician Supports mandate Yes No Missing values Sexually active Yes No Missing values
Total, n = 89, n (%)
African American, n = 31, n (%)
Haitian, n = 26, n (%)
Latino, n = 18, n (%)
White, n = 14, n (%)
19.1 (1.3)
19.2 (1.4)
19.1 (1.1)
18.6 (1.1)
19.7 (1.4)
52 (58) 37 (42)
16 (52) 15 (48)
16 (62) 10 (39)
14 (78) 4 (22)
6 (43) 8 (57)
28 (32) 33 (37) 28 (32)
14 (45) 9 (29) 8 (26)
4 (15) 12 (46) 10 (39)
6 (33) 10 (56) 2 (11)
4 (29) 2 (14) 8 (57)
86 (97) 2(3)
30 (97) 1 (3)
25 (96) 1 (4)
17 (94) 1 (6)
14 (100) 0
69 (78) 10 (11) 10 (11)
31 (100) 0 0
16 (62) 10 (38) 0
10 (56) 0 8 (44.4)
12 (86) 0 2 (14)
80 (90) 5 (6) 4 (4) 48 (54) 82 (92)
31 (100) 0 0 10 (32) 27 (87)
21 (81) 5 (19) 0 18 (69) 25 (96)
14 (78) 0 4 (22) 13 (72) 18 (100)
14 (100) 0 0 7 (50) 12 (86)
80 (91) 26 (30) 18 (21) 76 (85)
26 (84) 12 (39) 12 (39) 22 (71)
24 (92) 9 (35) 4 (15) 24 (92)
17 (100) 3 (18) 1 (6) 17 (94)
13 (93) 2 (14) 1 (7) 13 (93)
53 (60) 30 (34) 6 (7)
17 (55) 10 (32) 4 (13)
15 (58) 11 (42) 0 (0)
13 (72) 4 (22) 1 (6)
8 (57) 5(36) 1 (7)
49 (55) 9 (10) 31 (35)
16 (52) 2 (6) 13 (42)
18 (69) 3 (12) 5 (19)
does cost to get the vaccine.” African American and Haitian men also favored the protective benefits of vaccination; one African American man perceived the vaccine as a way “to be protected and to be safe to decrease my chances of getting STDs.” Participants from all backgrounds viewed HPV vaccination as beneficial to their health as well as public health. One African American man reported that he vaccinated, “Cuz, I don’t know when I’m gonna have sex and I wanna be protected when I do so I don’t infect anybody else.” One Caucasian man said that vaccination “would be the prevention of an epidemic or, you know, just stopping the spread of disease.” Some participants believed that public health benefits outweighed potential vaccination risks: “Well, it doesn’t take much to vaccinate people, so I guess it is helpful. Just go and get a shot and you are all set.”
9 (50) 2 (11) 7 (38.9)
P Value (ANOVA, χ2 or Fisher’s Exact Test)
6 (43) 2 (14) 6 (43)
.10 .18
.02 .82
