- Email: [email protected]
Attitudes and Perceptions of the HPV Vaccine in Caribbean and African-American Adolescent Girls and their Parents
J Pediatr Adolesc Gynecol (2010) 23:242e245
Original Study Attitudes and Perceptions of the HPV Vaccine in Caribbean and African-American Adolescent Girls and their Parents Dalan S. Read, MD1, Michael A. Joseph, PhD, MPH2, Veronika Polishchuk, BA3, and Amy L. Suss, MD1 1
Department of Pediatrics/Adolescent Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA; 2Department of Preventive Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA; 3Department of College of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
Abstract. Objective: To describe attitudes and perceptions toward acceptability of human papilloma virus (HPV) vaccination among inner city Caribbean (CA) and African American (AA) adolescents and their parents, and discuss correlates that may be associated with these factors. Design: Questionnaire survey. Setting: An adolescent medicine clinic. Participants: A convenience sample was recruited of 175 adolescent girls aged 13 to 19 years and 74 parents attending adolescent clinic. Intervention: Participants completed an anonymous confidential 10-minute questionnaire. Main outcome Measures: Data on knowledge about HPV, cervical cancer (CC), attitudes and acceptance of the HPV vaccine. Results: Responses of 175 adolescent girls and 74 parents were analyzed. Overall, 48.9% of the teens were sexually active (SA) and had a 2.2-fold greater odds (OR 5 2.21; 95% CI 5 1.13e4.36) of being interested in HPV vaccination versus girls who were not SA. While only 55.8% of girls knew what HPV is, this knowledge was significantly associated with knowing that most CC is caused by HPV (P ! 0.001) and with interest in receiving HPV vaccination (P ! 0.001). Less than half (44.5%) of adolescent girls were interested in receiving the HPV vaccine and only 37.5% of parents. There were no significant influences in parental acceptance of the vaccine with regard to age, ethnicity and educational level, insurance, and living situation.The majority of parents wanted the vaccine for its role in preventing CC. Conclusions: Although controversy surrounds HPV vaccine in regard to its supposed role in promoting SA, only a minority of our parents showed concern for that association. The level of acceptance of the HPV vaccine was overall lower than what has been reported among other racial/ethnic
populations. Knowledge about HPV and its association with CC were significantly associated with interest in getting the HPV vaccine and both parents and teens seem to accept the HPV vaccine more for its role in CC prevention.
Key Words. Attitudes—Vaccine—Adolescent— Parent—HPV—Caribbean—African American— Sexually transmitted infection
Introduction
Address correspondence to: Dalan Sow Read, MD, Division of Adolescent Medicine, SUNY Downstate Medical Center, Department of Pediatrics, Box 49, 450 Clarkson Ave, Brooklyn, NY 11203; E-mail: [email protected]
Currently 20 million people are reported to be infected with Human Papilloma Virus (HPV) in the United States with an overall incidence of 6.2 million HPV infections per year. HPV is the leading cause of cervical cancer (CC) in women with two high-risk serotypes, HPV-16 and HPV-18 causing 70% of CC. In the United States, CC rates have declined in recent years, due to the success of the screening and early treatment programs over the last 50 years. However, ethnic and minority groups remain disproportionately affected, with African American (AA) women having 50% higher incidence of CC compared with white women and slightly higher than national rates in ethnically diverse communities with immigrant populations. HPV vaccine has high efficacy in preventing HPV infection, CC, and genital warts. The Advisory Committee on Immunization Practices recommends HPV vaccine to be routinely given to 9-26 year old females regardless of sexual activity (SA) and prior HPV infection. Known risk factors predisposing to HPV infection and subsequent CC are the following: early debut in sexual activity, multiparity, smoking, long term use of oral contraceptives, and comorbidity with other sexually transmitted infections.
Ó 2010 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
1083-3188/$36.00 doi:10.1016/j.jpag.2010.02.002
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
Several recent studies have explored the attitudes and perceptions that influence the decision of virginal or SA adolescents and their parents to accept the HPV vaccine. Anticipated factors that would influence acceptance of the vaccine include knowledge about HPV infection and the role of HPV vaccine in CC prevention, and association of HPV with SA, as well as racial and cultural differences among attitudes toward and acceptance of the vaccine. A couple of recent studies conducted in rural areas of the United States showed that there was a significant racial difference in awareness, knowledge and beliefs about HPV vaccine1 and that intention to vaccinate was associated with more knowledge about HPV and belief that HPV vaccine is effective against CC.2 Several studies have explored the attitudes toward the vaccine among Latino women. One of them used a series of individual interviews with 40 Latina mothers of 7-14 year old daughters, found a high acceptance rate (80%) of the HPV vaccine. However, 78% of the Latina mothers interviewed have not heard of HPV and 68% of them knew nothing about CC. In this study the information regarding HPV was provided to the mothers prior to assessing acceptability of the vaccine. The two main motivating factors for vaccinating girls in this study were prevention of disease and protection of the child from cervical cancer.3 Another study confirmed high acceptance rate toward the Latino mothers (98%) when compared to non-Latino women (68.3%). Cervical cancer prevention was the main motivation for seeking vaccination.4 A recent population-based survey of Kentucky women (N 5 2169) showed a high rate of acceptance of vaccination for girls aged 10-15 years (70.2%).5 In regard to the controversy that surrounds HPV vaccine and its supposed role in promoting SA, parents had no objections to the vaccination of younger girls, and overall, previous studies demonstrate that acceptance of the HPV vaccine is mainly guided by motivation to prevent CC and that education about HPV infection significantly increases acceptance of the vaccine. It is also evident that there are differences in attitude toward the HPV among various racial groups. To this date, there have been no studies that directly explored the perceptions of the vaccine in the inner city AA community. Thus, it is the goal of this study to determine adolescent and parent’s attitudes and perceptions and possible barriers to acceptance of the HPV vaccine in a predominately urban, minority population. Methods The study sample comprised predominantly Caribbean (CA) and AA girls aged 13-19 years and their parents who were recruited from an urban, adolescent medicine
243
clinic, on days when the primary investigator was available. Questionnaires were administered from January 2007 to June 2008 after obtaining a verbal informed consent. All participants anonymously answered a structured, self-administered questionnaire that lasted approximately 15-20 minutes. The questionnaire elicited information on sociodemographic characteristics, knowledge of HPV and CC, and attitudes toward HPV vaccination. Questionnaires were obtained from 175 adolescent girls and 74 parents, and these groups formed the base sample population for all analyses. Statistical Analysis Chi-square analyses were conducted to determine factors significantly associated with interest in receiving HPV vaccine. Crude odds ratios (OR) and associated 95% confidence intervals (CI) were computed to determine the odds of interest in receiving HPV vaccine. All analyses were performed using the statistical package SPSS, version 17 (SPSS Inc, Chicago, IL). Statistical significance was set at a 2-tailed alpha level of 0.05. Results The majority of adolescent girls in our sample were 16 years old or younger (55.7 %), reported being AA (50.6%) or CA (39.3%) and were currently in high school or had less than a high school education (76.1%). Overall, 84.3% reported having a regular doctor and 75.7% reported getting routine medical checkups; however, neither of these characteristics was associated with knowledge that most CC is caused by HPV or interest in receiving HPV vaccination (P O 0.05 for each). Nearly half (48.9%) reported being SA (CA, 56.1%; AA, 46.4%; Hispanic, 47.1%), with an average debut at 14.9 years (SD 5 1.56) Table 1. The majority of girls who were SA reported having more than one lifetime sexual partner (59.5%). Being SA was not associated with knowledge that most CC is caused by HPV (P 5 0.587); however, it was associated with interest in HPV vaccination (P 5 0.013). That is, SA girls had a 2.2-fold greater odds (OR 5 2.21; 95% CI 5 1.13-4.36) of being interested in HPV vaccination versus girls who were not SA. Statistically significant findings suggested that an increasing number of lifetime sexual partners is associated with knowledge that most CC is caused by HPV (P 5 0.05), but not with interest in receiving HPV vaccination (P 5 0.07). Although few girls reported ever having a sexually transmitted disease (STD) (27.0%), only 63.2% reported always using condoms during sex. While only 55.8% of girls knew what HPV is, this knowledge was significantly associated with knowing that most CC is caused by HPV (P ! 0.001) and with interest in receiving HPV vaccination (P ! 0.001).
244
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
Table 1. Demographic, Health and Sexual Behavior Correlates of Knowledge that most Cervical Cancer Caused by HPV and Attitudes Toward HPV Vaccination among Girls Attending an Urban, Adolescent Clinic in Brooklyn, NY Know Most Cervical Cancer Caused by HPV? Characteristic
Total
Age (Years) N (%) 13-16 97 (55.7) 17-21 77 (44.3) Race/Ethnicity African American 85 (50.6) African Caribbean 66 (39.3) Hispanic 17 (10.1) Education Less than high school 118 (76.1) High school of more 37 (23.9) Has regular doctor Yes 140 (84.3) No 26 (15.7) Gets routine medical checkups Yes 128 (75.7) No 19 (11.2) Don’t know 22 (13.0) Sexually Active Yes 85 (48.9) No 89 (51.1) Number of lifetime sexual partners 1 32 (40.5) 2-4 34 (43.0) 5þ 13 (16.5) Ever had STD Yes 24 (27.0) No 65 (73.0) Frequency of condom use during sex Always 48 (63.2) Sometimes 28 (36.8) Know what HPV is Yes 96 (55.8) No 76 (44.2)
Yes
No
N (%) 44 (46.3) 45 (60.8)
N (%) 51 (53.7) 29 (39.2)
40 (48.8) 36 (55.4) 10 (58.8)
42 (51.2) 29 (44.6) 7 (41.2)
60 (52.2) 24 (66.7)
P-value
Interested in HPV vaccination? P-value
Yes
No
N (%) 37 (38.9) 36 (52.9)
N (%) 58 (61.1) 32 (47.1)
0.624
28 (34.6) 33 (54.1) 11 (64.7)
53 (65.4) 28 (45.9) 6 (35.3)
0.016
55 (47.8) 12 (33.3)
0.127
53 (47.3) 18 (52.9)
59 (52.7) 16 (47.1)
0.566
70 (51.1) 16 (64.0)
67 (48.9) 9 (36.0)
0.234
56 (42.7) 14 (58.3)
75 (57.3) 10 (41.7)
0.158
68 (54.0) 11 (61.1) 7 (33.3)
58 (46.0) 7 (38.9) 14 (66.7)
0.155
54 (43.5) 11 (64.7) 7 (38.9)
70 (56.5) 6 (35.3) 11 (61.1)
0.219
46 (54.8) 43 (50.6)
38 (45.2) 42 (49.4)
0.587
44 (54.3) 29 (34.9)
37 (45.7) 54 (65.1)
0.013
12 (38.7) 20 (58.8) 10 (76.9)
19 (61.3) 14 (41.2) 3 (23.1)
0.050
13 (41.9) 22 (71.0) 7 (53.8)
18 (58.1) 9 (29.0) 6 (46.2)
0.070
14 (60.9) 34 (52.3)
9 (39.1) 31 (47.7)
0.478
13 (56.5) 34 (56.7)
10 (43.5) 26 (43.3)
0.990
29 (60.4) 15 (53.6)
19 (39.6) 13 (46.4)
0.560
26 (57.8) 17 (63.0)
19 (42.2) 10 (37.0)
0.664
80 (84.2) 9 (12.0)
15 (15.8) 66 (88.0)
!0.001
57 (61.3) 16 (23.2)
36 (38.7) 53 (76.8)
!0.001
A total of 164 adolescent girls (93.7%) responded to the survey question on whether or not they were interested in receiving the HPV vaccine. Less than half (44.5%) were interested in receiving the HPV vaccine, while the remainder were either uninterested (15.2%) or unsure (40.2%). Not knowing enough about the vaccine because the vaccine is too new was the main reason cited by our sample of adolescent girls (40%) for not being interested in receiving the HPV vaccine. Additionally, 31.4% of adolescent girls were not interested in receiving the HPV vaccine because they believed they were too young to think about or to have sex. Among 72 parents who responded to the question if they would be interested in their daughter receiving the HPV vaccine, only 37.5% reported an interest in getting the HPV vaccine for their daughters while the remainder was either unsure (38.9%) or refused (23.6%). The most frequently cited explanation by parents refusing HPV vaccination for their daughters was not having enough information about the HPV
0.061
0.076
vaccination because it is too new (81%). A minority of parents (14.3%) expressed concern that their child is too young to think about or to have sex. While parental decision was not statistically significantly associated with parental age, educational level, insurance status or living situation (P O 0.05 for all), those parents who knew what HPV was had a 3.4-fold greater odds (OR 5 3.35; 95% CI 5 1.02-11.42) of expressing interest in their daughter receiving the HPV vaccine when compared to parents who did not know what HPV was. Discussion The prevalence of SA (48.9%) in our sample population of inner city CA and AA adolescent girls is slightly higher than what has been previously reported in nationwide data; estimates from the 2005 Youth Risk Behavior Survey indicated 46.8% of high school students were presently SA, with higher prevalence found among Black (43.8%) and Hispanic (33.7%)
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
female students.6 In a previous study, some parents expressed concern that vaccination might increase unsafe sexual behaviors,7 whereas another study found that parental attitudes were not affected by sexual transmission of HPV infection.8 Our hypothesis was that high level of SA in our sample will influence the interest of our adolescents and their parents to receive the HPV vaccine and may also raise concerns regarding the promotion of SA when offered to the younger adolescent age groups. While our results indicated statistically significant findings between SA status and interest in receiving HPV vaccination among adolescents, parents did not link promotion of SA when considering acceptance of HPV vaccination. Previous studies have shown that knowledge of HPV as an STD among adolescents and young women is low.9,10 Several studies have reported that the majority of the parents and adolescents had minimal knowledge about HPV and its association with CC10 and concluded that vaccine acceptance is improved with knowledge.7,11 In a study of 575 parents of their 10-15-year-old children, brief education significantly increased acceptance of an HPV vaccine, particularly in parents who initially were undecided.7 A relatively high percentage (55.8%) of our adolescent sample knew what HPV is. We found that knowledge about HPV was significantly associated with both parental and adolescent acceptance of the HPV vaccine. We acknowledge several limitations to our study. Our study population consisted of a convenience sample of teenage girls and their parents attending an urban, adolescent clinic serving a highly diverse minority population. Thus, any generalizations from this population are limited by the sociodemographic composition of our sample and the potential selection bias imposed by this sampling approach. Another issue that must be taken into consideration concerns the validity of self-reported information. Although confidentiality was promoted by having participants complete anonymous questionnaires in dedicated reserved areas, the sensitive nature of some questions might have influenced the likelihood of respondents giving honest, accurate responses. Finally, the crosssectional nature of our study prevents us from making any statements regarding causality; future longitudinal assessments are needed to assess whether intended acceptance of the HPV vaccine in our study population will lead to actual acceptance of the vaccine. Despite these limitations, this study provides novel data about attitudes toward HPV vaccination in a largely minority population of sexually experienced adolescent girls and their parents.
245
In conclusion, controversy surrounds HPV vaccine in regard to its supposed role in promoting sexual activity. However, only a minority of our parents (14.3%) showed concern to its association with sexual activity. In this inner city, CA and AA population where the prevalence of CC and HPV infection is disproportionately high, the level of acceptance of the HPV vaccine was overall lower than what has been reported among other racial/ethnic populations. Knowledge about HPV and its association with CC were significantly associated with interest in getting the HPV vaccine. Both parents and teens seem to accept the HPV vaccine more for its role in cancer prevention. Education about HPV and its association with CC can improve the perception and acceptance of the HPV vaccine in this population.
References 1. Cates JR, Brewer NT, Fazekas KI, et al: Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women. J Rural Health 2009; 25:93 2. Fazekas KI, Brewer NT, Smith JS: HPV vaccine acceptability in a rural Southern area. J Womens Health (Larchmt) 2008; 17:539 3. Bair RM, Mays RM, Sturm LA, et al: Acceptability of the human papillomavirus vaccine among Latina mothers. J Pediatr Adolesc Gynecol 2008; 21:329 4. Watts LA, Joseph N, Wallace M, et al: HPV vaccine: A comparison of attitudes and behavioral perspectives between Latino and non-Latino women. Gynecol Oncol 2009; 112:577 5. Christian WJ, Christian A, Hopenhayn C: Acceptance of HPV vaccine for adolescent girls: analysis of state-added questions from the BRFSS. J Adolesc Health 2009; 44:437 6. Eaton DK, Kann L, Kinchen S, et al: Youth risk behavior surveillanceeUnited States, 2005. MMWR Surveill Summ 2006; 55:1 7. Davis K, Dickman ED, Ferris D, et al: Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. J Low Genit Tract Dis 2004; 8:188 8. Zimet GD, Mays RM, Sturm LA, et al: Parental attitudes about sexually transmitted infection vaccination for their adolescent children. Arch Pediatr Adolesc Med 2005; 159:132 9. Clark LR, Jackson M, Allen-Taylor L: Adolescent knowledge about sexually transmitted diseases. Sex Trans Dis 2002; 29:436 10. Dell DL, Chen H, Ahmed F, et al: Knowledge about human papillomavirus among adolescents. Obstet Gynecol 2000; 96:653 11. Kahn JA, Rosenthal SL, Hamann T, et al: Attitudes about human papillomavirus vaccine in young women. Int J STD AIDS 2003; 14:300
Original Study Attitudes and Perceptions of the HPV Vaccine in Caribbean and African-American Adolescent Girls and their Parents Dalan S. Read, MD1, Michael A. Joseph, PhD, MPH2, Veronika Polishchuk, BA3, and Amy L. Suss, MD1 1
Department of Pediatrics/Adolescent Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA; 2Department of Preventive Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA; 3Department of College of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
Abstract. Objective: To describe attitudes and perceptions toward acceptability of human papilloma virus (HPV) vaccination among inner city Caribbean (CA) and African American (AA) adolescents and their parents, and discuss correlates that may be associated with these factors. Design: Questionnaire survey. Setting: An adolescent medicine clinic. Participants: A convenience sample was recruited of 175 adolescent girls aged 13 to 19 years and 74 parents attending adolescent clinic. Intervention: Participants completed an anonymous confidential 10-minute questionnaire. Main outcome Measures: Data on knowledge about HPV, cervical cancer (CC), attitudes and acceptance of the HPV vaccine. Results: Responses of 175 adolescent girls and 74 parents were analyzed. Overall, 48.9% of the teens were sexually active (SA) and had a 2.2-fold greater odds (OR 5 2.21; 95% CI 5 1.13e4.36) of being interested in HPV vaccination versus girls who were not SA. While only 55.8% of girls knew what HPV is, this knowledge was significantly associated with knowing that most CC is caused by HPV (P ! 0.001) and with interest in receiving HPV vaccination (P ! 0.001). Less than half (44.5%) of adolescent girls were interested in receiving the HPV vaccine and only 37.5% of parents. There were no significant influences in parental acceptance of the vaccine with regard to age, ethnicity and educational level, insurance, and living situation.The majority of parents wanted the vaccine for its role in preventing CC. Conclusions: Although controversy surrounds HPV vaccine in regard to its supposed role in promoting SA, only a minority of our parents showed concern for that association. The level of acceptance of the HPV vaccine was overall lower than what has been reported among other racial/ethnic
populations. Knowledge about HPV and its association with CC were significantly associated with interest in getting the HPV vaccine and both parents and teens seem to accept the HPV vaccine more for its role in CC prevention.
Key Words. Attitudes—Vaccine—Adolescent— Parent—HPV—Caribbean—African American— Sexually transmitted infection
Introduction
Address correspondence to: Dalan Sow Read, MD, Division of Adolescent Medicine, SUNY Downstate Medical Center, Department of Pediatrics, Box 49, 450 Clarkson Ave, Brooklyn, NY 11203; E-mail: [email protected]
Currently 20 million people are reported to be infected with Human Papilloma Virus (HPV) in the United States with an overall incidence of 6.2 million HPV infections per year. HPV is the leading cause of cervical cancer (CC) in women with two high-risk serotypes, HPV-16 and HPV-18 causing 70% of CC. In the United States, CC rates have declined in recent years, due to the success of the screening and early treatment programs over the last 50 years. However, ethnic and minority groups remain disproportionately affected, with African American (AA) women having 50% higher incidence of CC compared with white women and slightly higher than national rates in ethnically diverse communities with immigrant populations. HPV vaccine has high efficacy in preventing HPV infection, CC, and genital warts. The Advisory Committee on Immunization Practices recommends HPV vaccine to be routinely given to 9-26 year old females regardless of sexual activity (SA) and prior HPV infection. Known risk factors predisposing to HPV infection and subsequent CC are the following: early debut in sexual activity, multiparity, smoking, long term use of oral contraceptives, and comorbidity with other sexually transmitted infections.
Ó 2010 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Inc.
1083-3188/$36.00 doi:10.1016/j.jpag.2010.02.002
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
Several recent studies have explored the attitudes and perceptions that influence the decision of virginal or SA adolescents and their parents to accept the HPV vaccine. Anticipated factors that would influence acceptance of the vaccine include knowledge about HPV infection and the role of HPV vaccine in CC prevention, and association of HPV with SA, as well as racial and cultural differences among attitudes toward and acceptance of the vaccine. A couple of recent studies conducted in rural areas of the United States showed that there was a significant racial difference in awareness, knowledge and beliefs about HPV vaccine1 and that intention to vaccinate was associated with more knowledge about HPV and belief that HPV vaccine is effective against CC.2 Several studies have explored the attitudes toward the vaccine among Latino women. One of them used a series of individual interviews with 40 Latina mothers of 7-14 year old daughters, found a high acceptance rate (80%) of the HPV vaccine. However, 78% of the Latina mothers interviewed have not heard of HPV and 68% of them knew nothing about CC. In this study the information regarding HPV was provided to the mothers prior to assessing acceptability of the vaccine. The two main motivating factors for vaccinating girls in this study were prevention of disease and protection of the child from cervical cancer.3 Another study confirmed high acceptance rate toward the Latino mothers (98%) when compared to non-Latino women (68.3%). Cervical cancer prevention was the main motivation for seeking vaccination.4 A recent population-based survey of Kentucky women (N 5 2169) showed a high rate of acceptance of vaccination for girls aged 10-15 years (70.2%).5 In regard to the controversy that surrounds HPV vaccine and its supposed role in promoting SA, parents had no objections to the vaccination of younger girls, and overall, previous studies demonstrate that acceptance of the HPV vaccine is mainly guided by motivation to prevent CC and that education about HPV infection significantly increases acceptance of the vaccine. It is also evident that there are differences in attitude toward the HPV among various racial groups. To this date, there have been no studies that directly explored the perceptions of the vaccine in the inner city AA community. Thus, it is the goal of this study to determine adolescent and parent’s attitudes and perceptions and possible barriers to acceptance of the HPV vaccine in a predominately urban, minority population. Methods The study sample comprised predominantly Caribbean (CA) and AA girls aged 13-19 years and their parents who were recruited from an urban, adolescent medicine
243
clinic, on days when the primary investigator was available. Questionnaires were administered from January 2007 to June 2008 after obtaining a verbal informed consent. All participants anonymously answered a structured, self-administered questionnaire that lasted approximately 15-20 minutes. The questionnaire elicited information on sociodemographic characteristics, knowledge of HPV and CC, and attitudes toward HPV vaccination. Questionnaires were obtained from 175 adolescent girls and 74 parents, and these groups formed the base sample population for all analyses. Statistical Analysis Chi-square analyses were conducted to determine factors significantly associated with interest in receiving HPV vaccine. Crude odds ratios (OR) and associated 95% confidence intervals (CI) were computed to determine the odds of interest in receiving HPV vaccine. All analyses were performed using the statistical package SPSS, version 17 (SPSS Inc, Chicago, IL). Statistical significance was set at a 2-tailed alpha level of 0.05. Results The majority of adolescent girls in our sample were 16 years old or younger (55.7 %), reported being AA (50.6%) or CA (39.3%) and were currently in high school or had less than a high school education (76.1%). Overall, 84.3% reported having a regular doctor and 75.7% reported getting routine medical checkups; however, neither of these characteristics was associated with knowledge that most CC is caused by HPV or interest in receiving HPV vaccination (P O 0.05 for each). Nearly half (48.9%) reported being SA (CA, 56.1%; AA, 46.4%; Hispanic, 47.1%), with an average debut at 14.9 years (SD 5 1.56) Table 1. The majority of girls who were SA reported having more than one lifetime sexual partner (59.5%). Being SA was not associated with knowledge that most CC is caused by HPV (P 5 0.587); however, it was associated with interest in HPV vaccination (P 5 0.013). That is, SA girls had a 2.2-fold greater odds (OR 5 2.21; 95% CI 5 1.13-4.36) of being interested in HPV vaccination versus girls who were not SA. Statistically significant findings suggested that an increasing number of lifetime sexual partners is associated with knowledge that most CC is caused by HPV (P 5 0.05), but not with interest in receiving HPV vaccination (P 5 0.07). Although few girls reported ever having a sexually transmitted disease (STD) (27.0%), only 63.2% reported always using condoms during sex. While only 55.8% of girls knew what HPV is, this knowledge was significantly associated with knowing that most CC is caused by HPV (P ! 0.001) and with interest in receiving HPV vaccination (P ! 0.001).
244
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
Table 1. Demographic, Health and Sexual Behavior Correlates of Knowledge that most Cervical Cancer Caused by HPV and Attitudes Toward HPV Vaccination among Girls Attending an Urban, Adolescent Clinic in Brooklyn, NY Know Most Cervical Cancer Caused by HPV? Characteristic
Total
Age (Years) N (%) 13-16 97 (55.7) 17-21 77 (44.3) Race/Ethnicity African American 85 (50.6) African Caribbean 66 (39.3) Hispanic 17 (10.1) Education Less than high school 118 (76.1) High school of more 37 (23.9) Has regular doctor Yes 140 (84.3) No 26 (15.7) Gets routine medical checkups Yes 128 (75.7) No 19 (11.2) Don’t know 22 (13.0) Sexually Active Yes 85 (48.9) No 89 (51.1) Number of lifetime sexual partners 1 32 (40.5) 2-4 34 (43.0) 5þ 13 (16.5) Ever had STD Yes 24 (27.0) No 65 (73.0) Frequency of condom use during sex Always 48 (63.2) Sometimes 28 (36.8) Know what HPV is Yes 96 (55.8) No 76 (44.2)
Yes
No
N (%) 44 (46.3) 45 (60.8)
N (%) 51 (53.7) 29 (39.2)
40 (48.8) 36 (55.4) 10 (58.8)
42 (51.2) 29 (44.6) 7 (41.2)
60 (52.2) 24 (66.7)
P-value
Interested in HPV vaccination? P-value
Yes
No
N (%) 37 (38.9) 36 (52.9)
N (%) 58 (61.1) 32 (47.1)
0.624
28 (34.6) 33 (54.1) 11 (64.7)
53 (65.4) 28 (45.9) 6 (35.3)
0.016
55 (47.8) 12 (33.3)
0.127
53 (47.3) 18 (52.9)
59 (52.7) 16 (47.1)
0.566
70 (51.1) 16 (64.0)
67 (48.9) 9 (36.0)
0.234
56 (42.7) 14 (58.3)
75 (57.3) 10 (41.7)
0.158
68 (54.0) 11 (61.1) 7 (33.3)
58 (46.0) 7 (38.9) 14 (66.7)
0.155
54 (43.5) 11 (64.7) 7 (38.9)
70 (56.5) 6 (35.3) 11 (61.1)
0.219
46 (54.8) 43 (50.6)
38 (45.2) 42 (49.4)
0.587
44 (54.3) 29 (34.9)
37 (45.7) 54 (65.1)
0.013
12 (38.7) 20 (58.8) 10 (76.9)
19 (61.3) 14 (41.2) 3 (23.1)
0.050
13 (41.9) 22 (71.0) 7 (53.8)
18 (58.1) 9 (29.0) 6 (46.2)
0.070
14 (60.9) 34 (52.3)
9 (39.1) 31 (47.7)
0.478
13 (56.5) 34 (56.7)
10 (43.5) 26 (43.3)
0.990
29 (60.4) 15 (53.6)
19 (39.6) 13 (46.4)
0.560
26 (57.8) 17 (63.0)
19 (42.2) 10 (37.0)
0.664
80 (84.2) 9 (12.0)
15 (15.8) 66 (88.0)
!0.001
57 (61.3) 16 (23.2)
36 (38.7) 53 (76.8)
!0.001
A total of 164 adolescent girls (93.7%) responded to the survey question on whether or not they were interested in receiving the HPV vaccine. Less than half (44.5%) were interested in receiving the HPV vaccine, while the remainder were either uninterested (15.2%) or unsure (40.2%). Not knowing enough about the vaccine because the vaccine is too new was the main reason cited by our sample of adolescent girls (40%) for not being interested in receiving the HPV vaccine. Additionally, 31.4% of adolescent girls were not interested in receiving the HPV vaccine because they believed they were too young to think about or to have sex. Among 72 parents who responded to the question if they would be interested in their daughter receiving the HPV vaccine, only 37.5% reported an interest in getting the HPV vaccine for their daughters while the remainder was either unsure (38.9%) or refused (23.6%). The most frequently cited explanation by parents refusing HPV vaccination for their daughters was not having enough information about the HPV
0.061
0.076
vaccination because it is too new (81%). A minority of parents (14.3%) expressed concern that their child is too young to think about or to have sex. While parental decision was not statistically significantly associated with parental age, educational level, insurance status or living situation (P O 0.05 for all), those parents who knew what HPV was had a 3.4-fold greater odds (OR 5 3.35; 95% CI 5 1.02-11.42) of expressing interest in their daughter receiving the HPV vaccine when compared to parents who did not know what HPV was. Discussion The prevalence of SA (48.9%) in our sample population of inner city CA and AA adolescent girls is slightly higher than what has been previously reported in nationwide data; estimates from the 2005 Youth Risk Behavior Survey indicated 46.8% of high school students were presently SA, with higher prevalence found among Black (43.8%) and Hispanic (33.7%)
Read et al: HPV Vaccine Attitudes in Caribbean and African-American Girls and Parents
female students.6 In a previous study, some parents expressed concern that vaccination might increase unsafe sexual behaviors,7 whereas another study found that parental attitudes were not affected by sexual transmission of HPV infection.8 Our hypothesis was that high level of SA in our sample will influence the interest of our adolescents and their parents to receive the HPV vaccine and may also raise concerns regarding the promotion of SA when offered to the younger adolescent age groups. While our results indicated statistically significant findings between SA status and interest in receiving HPV vaccination among adolescents, parents did not link promotion of SA when considering acceptance of HPV vaccination. Previous studies have shown that knowledge of HPV as an STD among adolescents and young women is low.9,10 Several studies have reported that the majority of the parents and adolescents had minimal knowledge about HPV and its association with CC10 and concluded that vaccine acceptance is improved with knowledge.7,11 In a study of 575 parents of their 10-15-year-old children, brief education significantly increased acceptance of an HPV vaccine, particularly in parents who initially were undecided.7 A relatively high percentage (55.8%) of our adolescent sample knew what HPV is. We found that knowledge about HPV was significantly associated with both parental and adolescent acceptance of the HPV vaccine. We acknowledge several limitations to our study. Our study population consisted of a convenience sample of teenage girls and their parents attending an urban, adolescent clinic serving a highly diverse minority population. Thus, any generalizations from this population are limited by the sociodemographic composition of our sample and the potential selection bias imposed by this sampling approach. Another issue that must be taken into consideration concerns the validity of self-reported information. Although confidentiality was promoted by having participants complete anonymous questionnaires in dedicated reserved areas, the sensitive nature of some questions might have influenced the likelihood of respondents giving honest, accurate responses. Finally, the crosssectional nature of our study prevents us from making any statements regarding causality; future longitudinal assessments are needed to assess whether intended acceptance of the HPV vaccine in our study population will lead to actual acceptance of the vaccine. Despite these limitations, this study provides novel data about attitudes toward HPV vaccination in a largely minority population of sexually experienced adolescent girls and their parents.
245
In conclusion, controversy surrounds HPV vaccine in regard to its supposed role in promoting sexual activity. However, only a minority of our parents (14.3%) showed concern to its association with sexual activity. In this inner city, CA and AA population where the prevalence of CC and HPV infection is disproportionately high, the level of acceptance of the HPV vaccine was overall lower than what has been reported among other racial/ethnic populations. Knowledge about HPV and its association with CC were significantly associated with interest in getting the HPV vaccine. Both parents and teens seem to accept the HPV vaccine more for its role in cancer prevention. Education about HPV and its association with CC can improve the perception and acceptance of the HPV vaccine in this population.
References 1. Cates JR, Brewer NT, Fazekas KI, et al: Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women. J Rural Health 2009; 25:93 2. Fazekas KI, Brewer NT, Smith JS: HPV vaccine acceptability in a rural Southern area. J Womens Health (Larchmt) 2008; 17:539 3. Bair RM, Mays RM, Sturm LA, et al: Acceptability of the human papillomavirus vaccine among Latina mothers. J Pediatr Adolesc Gynecol 2008; 21:329 4. Watts LA, Joseph N, Wallace M, et al: HPV vaccine: A comparison of attitudes and behavioral perspectives between Latino and non-Latino women. Gynecol Oncol 2009; 112:577 5. Christian WJ, Christian A, Hopenhayn C: Acceptance of HPV vaccine for adolescent girls: analysis of state-added questions from the BRFSS. J Adolesc Health 2009; 44:437 6. Eaton DK, Kann L, Kinchen S, et al: Youth risk behavior surveillanceeUnited States, 2005. MMWR Surveill Summ 2006; 55:1 7. Davis K, Dickman ED, Ferris D, et al: Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. J Low Genit Tract Dis 2004; 8:188 8. Zimet GD, Mays RM, Sturm LA, et al: Parental attitudes about sexually transmitted infection vaccination for their adolescent children. Arch Pediatr Adolesc Med 2005; 159:132 9. Clark LR, Jackson M, Allen-Taylor L: Adolescent knowledge about sexually transmitted diseases. Sex Trans Dis 2002; 29:436 10. Dell DL, Chen H, Ahmed F, et al: Knowledge about human papillomavirus among adolescents. Obstet Gynecol 2000; 96:653 11. Kahn JA, Rosenthal SL, Hamann T, et al: Attitudes about human papillomavirus vaccine in young women. Int J STD AIDS 2003; 14:300