Rural African American parents' knowledge and decisions about human papillomavirus vaccination.

The Centers for Disease Control and Prevention (CDC) reports that certain strands of the Human Papillomavirus (HPV) are responsible for nearly 99% of cervical cancer cases and at least 20% of cancers of the head, neck, and anogenital areas (CDC, 2011b). The HPV vaccine can prevent many of these cancers if it is given to children at the recommended age of 11 to 12 years, and its safety and efficacy have been evaluated by both the CDC and the Food and Drug Administration (FDA; Paavonen et al., 2009). In June 2006, the FDA approved the vaccine for girls and then subsequently approved the vaccination for boys in 2010 (FDA, 2006, 2010). The Advisory Committee on Immunization Practices (ACIP) followed in October 2011 with the recommendations to vaccinate both girls and boys starting at age 11 to prevent the ever-increasing prevalence of HPV infection (Elbasha & Dasbach, 2010; Ferris, Horn, & Waller, 2010; Smith, Gilbert, Melendy, Rana, & Pimenta, 2011). Further, the CDC notes that, in rural Georgia, female completion rates for the HPV series are less than 18% and much lower than national rates (CDC, 2011a; Chou, Krill, Horton, Barat, & Trimble, 2011; Dempsey, Cohn, Dalton, & Ruffin, 2011; Jain et al., 2009). Recent research among U.S. men reveals that as few as 2% of males have received a dose of the HPV vaccine, and this number is likely to be even lower in rural areas (Reiter, McRee, Kadis, & Brewer, 2011). The findings imply that, in rural areas, the need for education on HPV transmission and the HPV vaccine is greater than first recognized (Rosenthal et al., 2008; Schluterman, Terplan, Lydecker, & Tracy, 2011). Early on, when the vaccine was first introduced for girls in 2006, controversies arose regarding the effects HPV vaccination might have on young girls, specifically, that it would cause promiscuity and a financial burden due the cost associated with the three-shot series, approximately $360 in total (Charo, 2007; Thomas, 2008). Among African American women and Latina immigrants who reside in urban areas, researchers found that African American women were more skeptical about the HPV vaccine than Latinas (Constantine & Jerman, 2007). Similarly, African American men know less about HPV infection and vaccination than Hispanics and non-Hispanic Whites (Daley et al., 2011). A study of African American parents’ and daughters’ acceptance of HPV implied that acceptance was low and related to sexual activity (Read, Joseph, Polishchuk, & Suss, 2010). The same study showed that knowledge of HPV and the HPV vaccine were significantly associated with parents’ interest in having their daughters vaccinated (Read et al., 2010). When parents understood the significance of HPV vaccination (cancer prevention) and that the reason for starting the series early was to elicit the best immune response, then an increased interest in having their child vaccinated occurred. The challenge of vaccine cost has been addressed, and the vaccine is now covered under the Vaccines For Children (VFC) program, with a maximum charge of $14.81 in Georgia, where this study was conducted (CDC, 2011c; Georgia Department of Public Health [GADPH], 2012). Understanding parental perceptions about the HPV vaccine is key to increasing vaccine rates, which are significantly lower among children from minority groups and children living in rural areas (Bynum et al., 2011). Currently, parental opinions on the HPV vaccine vary from one racial or ethnic group to another in rural areas, but frequently all ethnic groups had little access to HPV-related information (GADPH, 2012; Thomas, Strickland, DiClemente & Higgins, in press). This situation is particularly true for African Americans living in rural areas because the information that is available does not sufficiently describe the benefits of HPV vaccination in a way that overcomes fears and misperceptions (Cates, Brewer, Fazekas, Mitchell, & Smith, 2009). The need to vaccinate African Americans is particularly great because research findings indicate that African American adolescents take sexual risks at much higher rates than their White or Hispanic counterparts (Aral, Adimora, & Fenton, 2008). Moreover, rates of HPV-related cancers in rural areas are rarely researched, and there are limited data on rural populations by which to calculate the incidence of HPV-related cancers and cancer-related mortality (Lengerich et al., 2005). However, what we do know is that poverty and consequent health disparities contribute to higher rates of chronic disease in rural areas (“Management of clusters of sexually transmitted infection,” 2000). Many studies that focus on HPV vaccination were done in urban areas with participants who receive their medical care at clinics. The few studies that were done in rural areas focused only on young women and their acceptance of HPV vaccination or their decision to take a free vaccine (Brewer & Fazekas, 2007; Dempsey, Zimet, Davis, & Koutsky, 2006; Rosenthal et al., 2008). New findings reveal ethnic disparities in HPV vaccination among women and no association between HPV vaccination and high-risk sexual behavior (Liddon, Leichliter, & Markowitz, 2012). Few, if any, studies focused on parents with children, either boys or girls, 9 to 13 years of age. In addition, the Health Belief Model (HBM), while used in other vaccine research, had not been used as a theoretical framework in early HPV vaccine research, so both the measures and analysis were guided by these constructs to determine perceived vulnerability, perceived severity, perceived benefits, and perceived barriers to HPV vaccination for African American parents residing in rural Georgia (Rosenstock, Strecher, & Becker, 1988). This study’s objectives were (a) to determine the correlates of HPV vaccination among children of African American parents residing in rural areas and (b) to find culturally specific points of intervention that would increase HPV vaccination rates among children in rural African American communities.