Hispanic Health Care International, Vol. 12, No. 1, 2014
© 2014 Springer Publishing Company http://dx.doi.org/10.1891/1540-4153.12.1.24
Acceptability of the Human Papillomavirus Vaccine Among Diverse Hispanic Mothers and Grandmothers Michelle Ramírez, PhD, MPH Amy B. Jessop, PhD, MPH University of the Sciences in Philadelphia Amy Leader, DrPH, MPH Thomas Jefferson University, Philadelphia Carlos Juan Crespo, DrPH, MS Portland State University The human papillomavirus (HPV) vaccine has the potential to reduce rates of cervical cancer and other HPV-related morbidity among Hispanic women who are disproportionately affected by this disease. Understanding the barriers faced by this population is an important public health goal. In this qualitative pilot study, 17 mothers and grandmothers of adolescent girls from diverse Hispanic backgrounds in a large northeastern city in the United States were interviewed to examine attitudes regarding vaccine acceptability. The findings reveal that negative media, concerns about sexuality, side effects, and efficacy may impact vaccine uptake and completion. Of the 4 participants whose daughters had received the vaccine, only 1 had completed the full series, which may speak to the trend of lower series completion among Hispanics. This pilot data could inform important considerations when designing longitudinal research that may provide some necessary insights into the factors that facilitate or impede HPV vaccine completion among U.S. Hispanics. La vacuna contra el virus del papiloma humano (VPH), tiene el potencial de reducir las tasas de incidencia del cáncer de cuello uterino y de otras enfermedades relacionadas con el VPH entre las mujeres hispanas que se ven desproporcionadamente afectadas por estas enfermedades. Comprender las barreras que enfrentan las mujeres hispanas para vacunarse es una meta importante de salud pública. Diecisiete madres y abuelas de niñas adolescentes, de distintos orígenes hispanos residentes en una ciudad del noreste de los Estados Unidos, fueron entrevistadas para examinar sus actitudes relacionadas con la aceptabilidad de la vacuna. Los resultados del estudio mostraron que los mensajes negativos de los medios de comunicación, las preocupaciones acerca de la sexualidad, los efectos secundarios y la eficacia de la vacuna podrían afectar su aceptación y el cumplimiento de los esquemas de vacunación. De las cuatro participantes cuyas hijas habían recibido la vacuna, sólo una había cumplido con la serie completa, lo cual muestra la baja tendencia para completar el esquema de vacunación entre las hispanas. Este estudio piloto proporciona información importante, para diseñar un estudio longitudinal, sobre los factores que facilitan o impiden completar el esquema de vacunación contra el VPH entre las hispanas. Keywords: Hispanics; HPV vaccine; acceptability; qualitative research
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T
States, making HPV the most common sexually transmitted infection (Weinstock, Berman, & Cates, 2004). There are more than 100 types of HPV and roughly 40 types are transmitted sexually (Koutsky, 1997). Approximately 70% of cervical cancers are caused by types 16 and 18, and 90% of genital warts are caused by types 6 and 11 (Parkin & Bray, 2006). National data from Mexican American females showed that roughly one in four females were seropositive for at least one of these four types (Markowitz, Sternberg, Dunne, McQuillan, & Unger, 2009). Two HPV vaccines are licensed for use in the United States and are most efficacious if administered before exposure to HPV through sexual contact; therefore, the Advisory Committee on Immunization Practices (ACIP) recommends routine administration of the HPV vaccine to girls at ages 11 or 12 years (Centers for Disease Control and Prevention [CDC], 2010; Markowitz et al., 2007). Given the recommended age of vaccination, the vaccine’s acceptability to parents and caregivers is a critical issue for research (Garnett, Dubin, Slaoui, & Darcis, 2004; Mays, Strum, & Zimet, 2004; Zimet, 2006). With broad uptake, the HPV vaccine has the potential to reduce the burden of cervical cancer and other HPV-related disease.
he largest Hispanic subgroups residing in the United States are of Mexican, Puerto Rican, and Cuban origin (Hajat, Lucas, & Kington, 2000), and as of July 1, 2011, Hispanics became the nation’s largest ethnic minority (U.S. Census Bureau, 2012). Much of the growth of the Hispanic population is due to immigration from Mexico and other Latin American countries, where cervical cancer rates are among the highest in the world, with mortality rates seven times higher than in North America (Arrossi, Sankaranarayanan, & Parkin, 2003; Chavez, Hubbell, McMullin, Martinez, & Mishra, 1995; World Health Organization [WHO], 2012). In the United States, Hispanic women are diagnosed with cervical cancer almost twice as often as non-Hispanic White women (Downs, Smith, Scarinci, Flowers, & Parham, 2008). Moreover, recent geographic analysis found that Hispanic women experience the highest cervical cancer incidence rates of any racial/ethnic group in every region of the United States. (Watson et al., 2008). This is due, in part, to relatively low rates of cervical cancer screening. Current screening rates range from 71.0% among Hispanics from Central or South America to 77.7% among Hispanics from Puerto Rico, which is less than the 81.4% screening rate for nonHispanic White females (American Cancer Society, 2009). Research has demonstrated that cultural factors may play a role in the underutilization of cervical cancer screening by Hispanic women, in that “embarrassment” and a belief that only women who engage in unwise sexual behaviors need to be screened (Austin, McNally, & Stewart, 2002; Chavez et al., 1995; Harlan, Bernstein, & Kessler, 1991; Martinez, Chavez, & Hubbell, 1997; McMullin, De Alba, Chavez, & Hubbell, 2005; Modiano, 1995). Hispanic women may be equally dubious about health interventions such as the HPV vaccine because of its connection to cervical cancer, a disease apparently infused with culturally-based beliefs regarding appropriate female sexuality. Further, living in the United States may enhance concerns about a daughter’s sexuality among Hispanics. Espin (1997) contends that a daughter’s sexuality becomes a central focus of parental concern among Hispanic immigrants. Whereas Ayala (2006) notes that during the acculturation process, Hispanic mothers often frame sexuality within a discourse of danger, violence, and victimization and express intense concern over their daughter’s vulnerability to male sexuality, as virginity before marriage is still seen as a cultural ideal among many Hispanic groups (Lopez, 2008). Thus, concerns about preadolescent sexual activity can present barriers to HPV vaccine acceptance (Brewer & Fazekas, 2007; Luque, Castañeda, Martinez-Tyson, Vargas, & Meade, 2012).
Successes and Limitations in Vaccinating Hispanic Females Prior research, both in the United States and Mexico, has shown high acceptability rates of the HPV vaccine among Hispanic parents; however, many of the parents in these studies reported concerns about the efficacy of the vaccine, the side effects, and the possibility of it promoting early sexual behavior (Bair, Mays, Sturm, & Zimet, 2008; Lazcano-Ponce et al., 2001; Watts et al., 2009; Wu, Porch, McWeeney, Ohman-Strickland, & Levine, 2010; Yeganeh, Curtis, & Kuo, 2010). The potential for the vaccine to prevent cervical cancer was held in high regard by most parents, who generally agree that the benefits outweigh the risks when deciding whether to get their daughters vaccinated. Despite these positive indicators, Hispanic adolescent females in the United States face several barriers in accessing needed immunizations, which include a lack of stable health insurance and access to a regular health provider (Yeganeh et al., 2010). Although national data report that Hispanic females have higher vaccination initiation rates than their non-Hispanic counterparts (56.2% of females ages 13–17 years old, compared to 45.8% of White and 48.9% of Black females), Hispanic females have lower series completion rates (56.2% compared to 74.7% of White females and 65.4% of Black females; CDC, 2011).
Human Papillomavirus and the Human Papillomavirus Vaccine
Study Purpose This ethnographic-qualitative pilot study was undertaken in a large northeastern city in the United States among ethnically diverse Hispanic parents and grandparents. Ethnographic
Approximately 6.2 million new infections with human papillomavirus (HPV) will occur annually in the United 25
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methods are useful for defining the range and variability of phenomena that are not amenable to numerical measurement or statistical calculation (LeCompt & Schensul, 2010). The researchers’ objectives were to (a) explore general knowledge and attitudes about the HPV vaccine in this population, (b) examine cultural beliefs about female sexual chastity before marriage that may inform vaccine acceptance, and (c) develop hypotheses to be examined in future research. The use of ethnographic methods frame human behavior and belief within a sociopolitical context and use culture as a lens to interpret results (LeCompt & Schensul, 2010). These methods can help researchers and providers understand the sociocultural context that may inform attitudes about the HPV vaccine among Hispanics. Such an understanding may help facilitate the development of culturally appropriate educational and behavioral interventions aimed at increasing vaccination rates among Hispanic females, a population disproportionately burdened by cervical cancer.
Materials Consent forms and interview guides were translated from English to Spanish by a professional translation service. A semistructured interview guide was used as it is the most suitable instrument when the researcher has only one opportunity to interview a participant (Bernard, 2000). Participants received a $20 gift card thanking them for their participation. The study protocol received Human Subjects approval from the University of the Sciences’ Institutional Review Board.
Sample Determining sample size in qualitative, ethnographic research differs from that of quantitative research, in that there are no standardized power calculations available to make sample size determinations. There are, however, useful frameworks created by scholars working in the field of qualitative research that can guide decisions about sample size. Kuzel (1999) demonstrates that 5 to 8 sampling units will suffice for a homogeneous sample. However, several others note that 12 to 20 are commonly needed when looking for disconfirming evidence, or when trying to achieve maximum variation. Maximum variation occurs when a researcher seeks to obtain the broadest range of information and perspectives about a particular area of inquiry (Lincoln & Guba, 1985). By looking for this broad range of perspectives, the investigator is purposefully challenging her preconceived understandings of the phenomenon under study, which can also mitigate against the tendency to make the “messiness” of reality appear “neat and tidy” (Kuzel, 1999). Because this was a pilot study seeking maximum variation, the first author interviewed 16 Hispanic mothers and 2 grandmothers of adolescent girls. Grandmothers were not excluded because they were the primary caretakers of an adolescent girl and have been found to have significant influence regarding health and household decisions among Hispanic families (Allen et al., 2012). One participant was ineligible, as her daughters fell outside of the age specifications for the study, yielding a total of 17 participants.
Methods Setting and Recruitment This study was conducted in a predominantly Hispanic neighborhood (population approximately 45,000; 64% Hispanic), whose residents are mainly from Puerto Rico with a growing Dominican population. This is one of the poorest, underserved areas in the city with 41% of the population younger than 18 years of age, 53% with income less than 100% poverty level, and just 28% of adults with a high school diploma (University of Pennsylvania, Philadelphia Neighborhood Information System, 2012; U.S. Census Bureau, 2010). A local social service agency in the neighborhood agreed to support the primary investigator (MR) with office space to conduct interviews. MR also received recruitment guidance from community consultants working in the agency. Flyers in both English and Spanish describing this study were placed in strategic locations at the agency and in the windows of local businesses. Mothers and grandmothers who were the primary caretakers of adolescent and preadolescent daughters (ages 8–17 years) were purposively recruited by community outreach workers and by the primary investigator. To increase the social and ethnic diversity of the sample, we also recruited participants at a small outdoor health and informational fair sponsored by a local church, where MR sat at a table with information regarding the HPV vaccine and flyers describing this study. Thus, participants were recruited via word of mouth and snowball sampling by MR and a community outreach worker. When using the snowball sampling method, participants often lead the investigator to other research participants based on a designated set of criteria (Trotter & Schensul, 2000); in this case, other Hispanic parents with adolescent daughters.
Interviews and Data Analysis Participants were interviewed in English or Spanish by the primary investigator, depending on the language preference of the participant. Nine interviews were conducted in Spanish and 8 were conducted in English. MR conducted the interviews in the administrative offices in the social service agency, a family business, the outdoor fair, participant homes, and at a local church. Interviews were tape recorded on all but one occasion where the participant preferred not to be recorded. The interview began by asking participants what they knew about the HPV vaccine. If the parent had no knowledge of the vaccine, the interviewer explained that the 26
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TABLE 1. Participant Demographics
vaccine is administered to prevent both cervical cancer and genital warts, and that it is administered in three doses over a 6-month period and is recommended for girls ages 11–12 years. On some occasions, parents would initiate a discussion about sexuality concerns regarding the vaccine. On other occasions parents were asked, “Some parents think getting their daughters vaccinated with the HPV vaccine would encourage sexual activity, how do you feel about this?” At which point the parent would then discuss their views regarding the HPV vaccine and sexuality. At the time of this study, the vaccine had not yet been approved for boys, thus, the study questions focused on parental attitudes about the vaccine for girls. Interview data and field notes were transcribed and analyzed by the primary investigator in an iterative manner using an ethnographic, inductive approach where analysis was informed by themes identified in the literature and by the primary investigator’s personal reading of the data (Gregg, 2011). The primary investigator is a bilingual/bicultural medical anthropologist with significant expertise interviewing women regarding sensitive health matters, therefore, she took the lead in analyzing the data (Ramirez, 2006; Ramirez et al., 2009). She consulted with the coauthors about key methodological issues as they arose regarding sample size, sample composition, and neighborhood characteristics. Three of the four authors discussed coding disagreements and came to a consensus on the most appropriate way to describe neighborhood characteristics and vaccine status. Data were analyzed repeatedly as new themes and subthemes were identified (Higgins, Hirsch, & Trussell, 2008; Ryan & Bernard, 2000). MR hand coded interviews identifying themes and subthemes that captured participants’ attitudes about the HPV vaccine. The case studies and examples presented in this article were selected because they represent the typical patterns that emerged during the interviews.
Characteristic Age (years) Range Average Relationship Mother Grandmother Ethnicity Puerto Rican Dominican Mexican Mexican/Costa Rican Puerto Rican/Non-Hispanic White Marital status Married Cohabitating Separated Single Not available to researchers Language preference English Spanish Education Some primary Primary completed Some high school Some high school and vocational training High school completed Some college College completed (in country of origin) Employment Unemployed Employed Certified nurse assistant Family business House cleaning Social worker Customer service representative Retired Country of birth United States Outside United States Length of time in United States 1–5 years 6–10 years More than 10 years Entire life
Results Most of the participants were Puerto Rican, although other Hispanic groups were represented. Half of the participants were unemployed, receiving some form of government assistance, either supplemental social security income or welfare. Three out of the 17 had professional, servicesector jobs, and two women were retired (one from teaching, the other from house cleaning). All participants had health insurance—either employer-based programs or Medicaid/Medicare programs. Ten women had not completed high school, but 2 out of the 10 had completed vocational training where a high school degree was not required. Four women had completed high school, one was currently enrolled in an online legal studies program that would eventually lead to a bachelor’s degree, and three had completed a university degree in their country of origin. Table 1 displays participant demographics. 27
Number 26–76 30 15 2 11 2 1 2 1 6 2 3 2 4 8 9 1 2 4 2 4 1 3 8 1 3 1 1 1 2 11 6 1 3 5 8
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that it was a preventive vaccine. The mother then asked her 16-year-old daughter what she wanted to do, and the daughter agreed to get the vaccine; at the time of the interview, the daughter was only missing the third shot. Two other Puerto Rican mothers, both of whom had graduated from high school, noted that the reason they had initiated the vaccine for their daughters was to protect them against cervical cancer. One noted a family history of cancer and had initiated the vaccine series for her daughter in Puerto Rico and was hoping to get the third injection in the United States. The other participant had been diagnosed with cervical cancer and her daughter had received the complete series. A familial and personal experience with cervical cancer motivated these women to get their daughters vaccinated to protect them against the disease. A Mexican immigrant woman, college educated in Mexico, reported that her mother died of cervical cancer. This participant had also received treatment for early stage cervical cancer, thus like the Puerto Rican mothers mentioned earlier, she also wanted to protect her child from this disease. This woman’s daughter had received the first two shots; however, at the time of the interview, the daughter was outside of the recommended 6-month window for the third dose. She said that at her daughter’s next physical, she would ask about the third dose. Amidst our discussion, she mentioned concerns about immigration issues and side effects related to the HPV vaccine. She had been hearing through various Spanish language media that the vaccine was mandatory for individuals seeking legal residency, which was creating quite a stir in the Mexican immigrant community. She mentioned that it was not fair to obligate immigrants to receive the vaccine while allowing citizens to make their own decisions about it. She also noted that she was afraid of the potential side effects that she heard about. However, a friend from Puerto Rico assured the participant that her daughter had received the full series and was not suffering any ill effects, thus encouraging the participant to make sure her daughter received the final dose of the vaccine. Vaccination Not Initiated. Many of the parents in this category had limited knowledge about the HPV virus and vaccine and were unaware that HPV is sexually transmitted. Some had heard about the vaccine and its connection to cervical cancer but did not know that it also prevents most strains of genital warts. After the brief description was provided, the mothers expressed positive views about it; however, concerns were also expressed. Major subthemes guiding positive attitudes toward the vaccine were once again—fear of cancer, protecting their daughter against cancer, and physician recommendation. Although the vaccine was found to be acceptable by all parents, there were concerns expressed about vaccine efficacy, potential side effects, and cost. And although sexuality did not appear to be a central concern regarding vaccine acceptance, the issue came up in interesting ways.
Categories and Themes Because the study sought to achieve maximum variation regarding attitudes among Hispanic parents, individuals were recruited regardless of their daughter’s vaccine status. Thus, the first major category or theme to emerge within the sample was—parents whose daughters had received the vaccine, those parents whose daughters had not received the vaccine, and one parent who was unsure about whether the vaccine her daughter received was the HPV vaccine. We are calling these three categories: (a) vaccine initiated (n 5 4), (b) vaccine not initiated (n 5 12), and (c) unsure of vaccine status (n 5 1). Among the vaccine initiates, three parents were in the process of getting their daughters vaccinated; their daughters had received two of the three shots; however, only one girl had received the full series. The remaining 12 mothers and grandmothers had not initiated the vaccine for their daughters/granddaughters. Within the three vaccine status categories, two themes arose regarding vaccine acceptance and vaccine concerns. The subthemes listed in Table 2, under acceptance and concern, are perspectives and experiences that appeared to promote vaccine acceptance or vaccine concern. Discussions about vaccine acceptance and vaccine concerns are discussed in the following text within the category of vaccine status, which further reveals the complexity of HPV-vaccine acceptance. For example, even when a parent initiated the series for their daughters, some continued to express various concerns about it. Moreover, many of the subthemes overlapped within the course of a conversation with a participant, thus, rather than extracting quotes to provide thematic exemplars, we are providing a more naturalistic representation of how the parents discussed their opinions and concerns about the HPV vaccine; we feel that the conversational and ethnographic context more accurately capture parental attitudes. Vaccine Initiated. One college-educated, Puerto Rican mother who was recruited at the health fair, a selfdescribed devout Christian, noted that at first she was concerned about the vaccine’s implications regarding her daughter’s sexuality but was told by her physician
TABLE 2. Coding Themes and Subthemes Themes Vaccine Acceptance
Vaccine Concerns Subthemes
Physician recommendation
Sexuality
Protection against cancer
Side effects
Fear of cancer
Immigration
Family/personal experience with cancer
Efficacy Cost 28
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Two Puerto Rican mothers, who were born in the continental United States, expressed positive attitudes regarding the vaccine but were unsure about its efficacy and side effects. One mother said that she was, “A little scared cuz’ I don’t know like, the side effects of it, or if it really does prevent it [cervical cancer]” while the other noted that she had heard from her cousin that the vaccine helped her “fight off” cancer, so she was going to ask her doctor whether or not the vaccine actually prevents cancer. A Mexican American mother with a 10th-grade education seemed very unsure about whether or not to get her daughter vaccinated. This participant had actually been diagnosed with early stage cervical cancer for which she had received treatment and described the process as “very stressful” and wanted to protect her daughter from going through a similar ordeal. However, she had also heard in the news that there are side effects associated with the vaccine and was conflicted about whether or not to get her daughter vaccinated. Furthermore, her husband was not in favor of the vaccine because he believed that it would promote early sexual activity. She also expressed concern about a vaccine that would allow her daughter to think that she could have sex without “getting diseases.” Her approach to this dilemma was to not tell her daughter what the vaccine was for: “I wouldn’t tell her, I would just get it like a regular shot and then when she’s older, I’ll let her know when she’s already active, I wouldn’t like the doctor to lecture her.” This mother further noted that if she did decide to get her daughter vaccinated, she would not tell her husband, “I’m the one who takes her to the doctor, so he doesn’t have to know. It’s up to me, it would be down to me in the end.” A 66-year-old Puerto Rican grandmother, who was college educated in Puerto Rico and is the full-time caretaker of her granddaughter, actually knew quite a bit about the vaccine and stated, “I am convinced that it is necessary.” For this participant, cancer is a disease like any other disease such as tetanus or polio for which you can be vaccinated, thus the HPV vaccine should not be connected to sexuality. However, she noted that “a lot of people don’t believe this because they have the taboo that giving the vaccine to the girl is giving her permission to freely have sex.” This woman’s granddaughter had lived with her from the age of 2–11 years in Puerto Rico because the girl’s mother died. The participant’s son (the girl’s father) remarried and moved to Chicago, at which point, the girl moved back in with her father and stepmother and lived with them from age 11 to 15 years. However, because of familial conflicts, the granddaughter chose to live with her grandmother again and has been living full time with the participant for the last year and a half. This brief residence history is germane because the participant was convinced that the reason why her granddaughter had not received the HPV vaccine was because of her son’s more traditional way of thinking. She noted that “men have a different point of view” because her son’s father (her ex-husband)
was someone who believed you should not talk to your children about sex and was convinced that her son had the same perspective, therefore had not initiated the vaccine for his daughter. Now that her granddaughter was living with the participant, she was going to speak to the girl’s doctor about getting her vaccinated. An unmarried, 28-year-old Puerto Rican woman with a ninth-grade education was the mother of six children. At first, it appeared that she had very little knowledge about the HPV vaccine, but during the brief description, she remembered she had read that the virus caused cervical cancer from materials that accompanied a douching product. This participant was unclear about the precise cause of HPV so MR explained that it was sexually transmitted. After the description, MR asked the participant how she would feel about vaccinating her daughter, at which point she stated, “It would be great, cuz’ I don’t want her to get no kind of disease.” MR asked if she believed that the vaccine would promote sexual activity to which the participant replied: No I don’t think so . . . maybe women have to talk about it more. I’m not giving her permission to be sexually active but you know just in case because I can’t stop her . . . she could probably do it behind my back, but I will talk to her about it . . . Every woman would wish that they could wait till they’re married, but that’s not gonna happen. It depends on how they’re growing, on the parents, on the relationship with their mother and daughter.
This mother articulates a wish that “every woman” would want for themselves and their daughters—the cultural ideal of chastity before marriage, but seems to believe that it is unlikely to be upheld. Therefore, it is important for mothers to be realistic and to have the kind of relationship with their daughters where they can openly discuss issues related to sexuality. A college educated, Evangelical, U.S. born Dominican woman, was the mother of seven children, five of whom were girls aged 20, 17, 11, 9, and 7 years, had heard very little about the HPV vaccine prior to the interview. After the description, the participant noted that she would like to have her daughters vaccinated given that “cancer is a very scary word” and was concerned about protecting her children, and also noted, “I don’t care about the sex part, I care about protecting my kids, since there’s no cure, might as well prevent it.” This mother also commented that she believes that Hispanics who do not have much education might be more inclined to worry about the vaccine’s connection to sexuality. She also mentioned that her experience as a customer service representative for an insurance company has made her more aware of the high prevalence of cancer among women, which she noted might also make her more inclined to accept the HPV vaccine for her daughters. Although this mother seemed very positive about the vaccine’s ability to prevent cervical cancer, follow-up research would be necessary to see if she has indeed initiated the vaccination process for any of her daughters. 29
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a sixth-grade education did not know the name of the vaccine her daughter had just received but still wanted her daughter to be protected against cervical cancer. Hispanics have the lowest educational attainment levels of all ethnic groups in the United States (The White House, 2011) and may require additional efforts on the part of providers to make sure Hispanic parents are indeed making informed decisions about childhood vaccines (VanSlyke et al., 2008). However, providers should not necessarily assume low educational levels even if their Hispanic patient is monolingual. Three women in this study were college educated; two were educated in their home countries and were monolingual. Interestingly, the college-educated Mexican woman faced a much different social reality in her decision making about the vaccine. At the time of the interview, this woman’s daughter had received the first two injections of the series but was unsure about whether or not the vaccine was mandatory for legal residency. According to Section 212 of the Immigration and Nationality Act (INA) immigrants who wish to be lawfully admitted to the United States were mandated to receive vaccinations against vaccine-preventable diseases recommended by the ACIP. At the time this study was undertaken, the mandate also applied to the HPV vaccine. However, Puerto Ricans, even if they are immigrants, are also American citizens; therefore, this temporary law would not have applied to them. The HPV vaccine mandate has since been rescinded, but at this particular moment in the vaccine’s social history, there was a different decision making playing field for different Hispanic groups regarding HPV vaccine. Thus, providers and policy makers should be attuned to different political-economic realities among different Hispanic groups that may inform vaccine uptake and completion (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005). Also, germane to the current discussion is the Mexican mother’s mention of a friend whose daughter had received all three doses of the HPV vaccine and was not experiencing any adverse side effects, thus encouraging the participant to do the same—possibly suggesting a role for lay, or peer health advisors in vaccine completion. Another concern articulated by several mothers in this study was related to the vaccine’s potential side effects. Again during the summer of 2009, the HPV vaccine received a great deal of negative media attention. A front-page article in a local weekly newspaper was titled, “Risky Business: One Teen says Gardasil Wrecked Her Life” (Murtha, 2009). The article followed the story of an 18-year-old young woman named “Victoria” who reportedly suffered nonepileptic seizures, migraines, and fainting spells in addition to many other severe symptoms; all of which she and her mother attributed to receiving the second dose of Gardasil. Negative media attention may indeed confound decision making for parents: A Texas study found that parental concerns about vaccine safety and
Finally, an Evangelical grandmother from the Dominican Republic stated, “I think it’s very important to avoid cancer” and did not believe that it would promote sexuality in her granddaughter because her granddaughter is also Christian, but then also added that “there is no money for it, it is a little bit expensive.” Unsure of Vaccine Status. A Puerto Rican mother, who was unsure about the vaccine her 12-year-old daughter had just received, has lived in the United States her entire life and has a sixth-grade education. This mother echoes the desire to protect her daughter from cancer and discusses a familial history of cervical cancer: She got her last shot at 12, but I’m not too sure if it was this one, I don’t remember him telling me the name. I would like it, I would like for her to get it, you know, if it’s going to help for her future, I would love to have her protected. My mom had cervical cancer . . . so it runs in my family genes.
Discussion Although most participants did not cite sexuality as a barrier to vaccine uptake, concerns or reflections about sexuality did appear in some of the discussions. One mother noted that sexual chastity before marriage, although desirable, was unlikely, thus it may be necessary for mothers to talk openly with their daughters rather than assuming they will not be sexually active. For others, such concerns were overridden by the importance of cancer prevention and physician recommendation. Although, one mother did not want a physician lecturing her daughter about what the vaccine is for, which highlights once again potential complexities attached to STI vaccines. This participant, along with one of the grandmothers interviewed, perceived that male family members are concerned about the HPV vaccine’s connection to female adolescent sexuality, highlighting possible gender differences among Hispanic men and women and their beliefs about the HPV vaccine. One mother noted, however, that it would be her decision “in the end,” because she is the one who takes her daughter to the doctor. Among the vaccine initiates, only one daughter out of the four had completed the three-dose series, which may be a reflection of the overall lower series completion rates among this population (CDC, 2011) but is noteworthy for the following reasons: All of the participants in this study had some type of health insurance and did not report difficulty obtaining medical care. Second, this study was conducted in a city nationally recognized for its childhood vaccine delivery programs; therefore, there may be host of political, economic, and sociocultural factors that interfere with HPV vaccine completion. What is also potentially noteworthy about the findings from this small pilot study is the diversity of experiences based on factors such as education, ethnicity, and immigration status. A Puerto Rican mother with 30
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negative media were the most commonly encountered barriers to vaccine uptake (Kahn et al., 2009). Moreover, the HPV vaccine has had its share of media controversy— consider the more recent claims made by former U.S. presidential Republican candidate Michele Bachmann (Pearson, 2011). Thus at any given time, providers may need to be aware of the media messages generated about the HPV vaccine and may have to reassure parents that the vaccine is indeed safe and efficacious, as concerns also emerged regarding the efficacy of the vaccine. The frequency with which either a personal or familial experience with cervical cancer was discussed continues to remind medical providers and researchers of the burden this disease has on Hispanic women. It could be that women interested in participating in this study selfselected because of a personal or familial experience with cervical cancer; however, not all women who participated knew or understood the purpose of the vaccine. The mothers who initiated the series for their daughters all wanted to protect them from cervical cancer, particularly if there is a family history of cervical cancer. Therefore, the impact of cancer prevention should be highlighted when providing education about the HPV vaccine to Hispanic parents. Indeed, research has shown that although concerns about adolescent sexuality can negatively affect HPV vaccination intention among Hispanics, belief in illness prevention and physician recommendation may positively affect vaccine intention (Luque et al., 2012).
to receiving preventive care that address this health disparity—such as the HPV vaccine—are important for providers and policy makers to address in a culturally competent manner. In this small pilot study, concerns about adolescent sexuality and side effects persist about the HPV vaccine. However, these concerns can be overcome via provider recommendation. Future research could examine whether gender differences exist among Hispanic parents regarding attitudes about the HPV vaccine and whether more socially conservative male attitudes affect vaccine uptake and completion. Also suggested by this pilot project is examining the role that peer support can play in HPV vaccine uptake and completion. Education and outreach for the vaccine may also need to be attuned to various political-economic differences among Hispanic parents and negative media attention that can confound decision making. Further, aggregated statistics that present Hispanic health as a single unified category may belie a host of social and political differences within this ethnic group that may inform health decision making. Lastly, data have shown that although Hispanic parents are not less likely to initiate the vaccine, Hispanic girls are less likely to have completed the series; thus, more research, preferably a longitudinal study design, is necessary to determine the precise political, economic, and socio cultural factors that inform vaccine completion.
References Limitations
Agency Information Collection Activities; Proposals, Submis sions, and Approvals, 74 Fed. Reg. 15985–15986 (April 8, 2009). Allen, J. D., de Jesus, M., Mars, D., Tom, L., Cloutier, L., & Shelton, R. C. (2012). Decision-making about the HPV vaccine among ethnically diverse parents: Implications for health communications. Journal of Oncology, 2012, 401979. http://dx.doi.org/10.1155/2012/401979. American Cancer Society. (2009). Cancer facts and figures for Hispanics/Latinos 2009–2011. Atlanta, GA: Author. Arrossi, S., Sankaranarayanan, R., & Parkin, D. M. (2003). Incidence and mortality of cervical cancer in Latin America. Salud Publica Mexicana, 45(Suppl. 3), S306–S314. Austin, L. T., McNally, M. J., & Stewart, D. E. (2002). Breast and cervical cancer screening in Hispanic women: A literature review using the health belief model. Women’s Health Issues, 12(3), 122–128. Ayala, J. (2006). Confianza, consejos, and contradictions: Gender and sexuality lessons between Latina adolescent daughters and mothers. In J. Denner & B. Guzman (Eds.), Latina girls: Voices of adolescent strength in the United States (pp. 29–43). New York, NY: New York University Press. Bair, R. M., Mays, R. M., Sturm, L. A., & Zimet, G. D. (2008). Acceptability of the human papillomavirus vaccine among Latina mothers. Journal of Pediatric and Adolescent Gynecology, 21, 329–334. Bernard, H. R. (2000). Social research methods: Qualitative and quantitative approaches. Thousand Oaks, CA: Sage.
Qualitative methods capture diversity and complexity, however, cannot be used to make generalizations about populations. This was a small and diverse sample of Hispanic mothers and grandmothers in an urban northeastern region of the United States. Hispanic parents in rural regions of the United States or agricultural workers may have very different views about the HPV vaccine. However, urban centers are important to consider because this is where a great deal of population growth is occurring and diversifying. The primary investigator consulted with key members of the team regarding methodological and thematic issues as they arose; however, she conducted most of the analysis and interpretation of results, therefore, reflect her observational and analytical biases. Although these findings may not be generalizable, they can be understood as important first steps to developing hypotheses to be examined and tested in future research.
Conclusions and Recommendations Considering that Hispanics are the fastest growing minority in the United States and that Hispanic women are disproportionately burdened with cervical cancer, barriers 31
Ramírez et al. Brewer, N. T., & Fazekas, K. I. (2007). Predictors of HPV vaccine acceptability: A theory-informed systematic review. Preventive Medicine, 45, 107–114. Centers for Disease Control and Prevention. (2010). FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 59(20), 626–629. Centers for Disease Control and Prevention. (2011). National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. Morbidity and Mortality Weekly Report, 60(33), 1117–1123. Chavez, L. R., Hubbell, F. A., McMullin, J. M., Martinez, R. G., & Mishra, S. I. (1995). Structure and meaning in models of breast and cervical cancer risk factors: A comparison of perceptions among Latinas, Anglo women, and physicians. Medical Anthropology Quarterly, 9(1), 40–74. Downs, L. S., Smith, J. S., Scarinci, I., Flowers, L., & Parham, G. (2008). The disparity of cervical cancer in diverse populations. Gynecologic Oncology, 109, S22–S30. Espin, O. (1997). Latina realities: Essays on healing, migration and sexuality. Boulder, CO: Westview Press. Garnett, G. P., Dubin, G., Slaoui, M., & Darcis, T. (2004). The potential epidemiological impact of a genital herpes vaccine for women. Sexually Transmitted Infection, 80, 24–29. Gregg, J. (2011). An unanticipated source of hope: Stigma and cervical cancer in Brazil. Medical Anthropology Quarterly, 25(1), 70–84. Hajat, A., Lucas, J. B., & Kington, R. (2000). Health outcomes among Hispanic subgroups: Data from the national health interview survey, 1992-95. Advanced Data (National Center for Health Statistics), 310, 1–14. Harlan, L. C., Bernstein, A. B., & Kessler, L. G. (1991). Cervical cancer screening: Who is not screened and why? American Journal of Public Health, 81, 885–891. Higgins, J., Hirsch, J. S., & Trussell, J. (2008). Pleasure, prophylaxis and procreation: A qualitative analysis of intermittent contraceptive use and unintended pregnancy. Perspectives on Sexual and Reproductive Health, 40(3), 130–137. Kahn, J. A., Cooper, H. P., Vadaparampil, S. T., Pence, B. C., Weinberg, A. D., LoCoco, S. J., & Rosenthal, S. L. (2009). Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: A statewide survey of Texas physicians. Cancer Epidemiology, Biomarkers and Prevention, 18(8), 2325–2332. Koutsky, L. (1997). Epidemiology of genital human papillomavirus infection. American Journal of Medicine, 102, 3–8. Kuzel, A. (1999). Sampling in qualitative inquiry. In B. F. Crabtree & W. L. Miller (Eds.), Doing qualitative research (2nd ed., pp. 33–45). Thousand Oaks, CA: Sage. Lara, M., Gamboa, C., Kahramanian, M. I., Morales, L. S., & Hayes Bautista, D. E. (2005). Acculturation and Latino health in the United States: A review of the literature in its sociopolitical context. Annual Review of Public Health, 26, 367–397. Lazcano-Ponce, E., Rivera, L., Arillo-Santillan, E., Salmeron, J., Hernandez-Avila, M., & Munos, N. (2001). Acceptability of a human papillomavirus (HPV) vaccine trial among mothers of adolescents in Cuernavaca, Mexico. Archives of Medical Research, 32, 243–247.
LeCompt, M. D., & Schensul, J. J. (2010). Designing and conducting ethnographic research: An introduction (2nd ed.). New York, NY: AltaMira Press. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Los Angeles, CA: Sage. Lopez, I. (2008). Matters of choice: Puerto Rican women’s struggle for reproductive freedom. Rutgers, NJ: Rutgers Press. Luque, J. S., Castañeda, H., Martinez-Tyson, D., Vargas, N., &, Meade, C. D. (2012). Formative research on HPV vaccine acceptability among Latina farmworkers. Health Promotion Practice, 13(5), 617–625. Markowitz, L. E., Dunne, E. F., Saraiya, M., Lawson, H. W., Chesson, H., & Unger, E. R. (2007). Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 56(RR-2), 1–24. Markowitz, L. E., Sternberg, M., Dunne, E. F., McQuillan, G., & Unger, E. (2009). Seroprevalence of human papillomavirus types 6,11,16, and 18 in the United States: National Health and Nutrition Examination Survey, 2003-2004. Journal of Infectious Diseases, 200, 1059–1067. Martinez, R. G., Chavez, L. R., & Hubbell, F. A. (1997). Purity and passion: Risk and morality in Latina immigrants’ and physicians’ beliefs about cervical cancer. Medical Anthropology Quarterly, 17, 337–362. Mays, R. M., Strum, L. A., & Zimet, G. D. (2004). Parental perspectives on vaccinating children against sexually transmitted infections. Social Science & Medicine, 58, 1405–1413. McMullin, J. M., De Alba, I., Chavez, L. R., & Hubbell, F. A. (2005). Influence of beliefs about cervical cancer etiology on Pap smear use among Latina immigrants. Ethnicity and Health, 10(1), 3–18. Modiano, M. R. (1995). Breast and cervical cancer in Hispanic women. Medical Anthropology Quarterly, 9(1), 75–79. Murtha, T. (2009, June). Shot through the heart, the HPV vaccine: Lifesaver or Russian roulette? Philadelphia Weekly, 15–29. Parkin, D. M., & Bray, F. (2006). Chapter 2: The burden of HPVrelated cancers. Vaccine, 24(Suppl. 3), 11–25. Pearson, C. (2011). She said what? The Women’s Health Activist, 36(6), 2. Ramirez, M. (2006). Manufacturing heterosexuality: Hormone replacement therapy and menopause in In Urban Oaxaca. Culture, Health and Sexuality, 8(6), 545–558. Ramirez, M., McMullen, C., Grant, M., Altschuler, A., Hornbrook, M. C., & Krouse, R. (2009). Figuring out sex in a reconfigured body: Experiences of female colorectal cancer survivors with ostomies. Women & Health, 49(8), 608–624. Ryan, G., & Bernard, H. R. (2000). Techniques to identify themes. Field Methods, 15(1), 85–109. Trotter, R. T., & Schensul, J. J. (2000). Methods in applied anthropology. In H. R. Bernard (Ed.), Handbook of m ethods in cultural anthropology (pp. 691–735). Lanham, MD: Altamira Press. The White House. (2011). Winning the future: Improving education for the Latino community. Retrieved from http:// www.whitehouse.gov/sites/default/files/rss_viewer/ WinningTheFutureImprovingLatinoEducation.pdf University of Pennsylvania, Philadelphia Neighborhood Information System. (2012). Retrieved from http://cml .upenn.edu/nbase/nbProfileAction.asp 32
Acceptability of the HPV Vaccine U.S. Census Bureau. (2010). Profile of General Population and Housing Characteristics: 2010. Retrieved November 8, 2012 from http://censtats.census.gov/ U.S. Census Bureau. (2012). Hispanic Heritage Month 2012: Sept. 15–Oct. 15. Retrieved from http://www.census.gov/ newsroom/releases/pdf/cb12ff-19_hispanic.pdf VanSlyke, J. G., Baum, J., Plaza, V., Otero, M., Wheeler, C., & Helitzer, D. L. (2008). HPV and cervical cancer testing and prevention: Knowledge, beliefs, and attitudes among Hispanic women. Qualitative Health Research, 18(5), 584–596. Watson, M., Saraiya, M., Benard, V., Coughlin, S., Flowers, L., Cokkinides, V., . . . Guiliano, A. (2008). Burden of cervical cancer in the United States, 1998-2003. Cancer, 113(10, Suppl.), 2855–2864. Watts, L. A., Joseph, N., Wallace, M., Rauh-Hain, J. A., Muzikansky, A., Growdon, W. B., & del Carmen, M. G. (2009). HPV vaccine: A comparison of attitudes and behavioral perspectives between Latino and non-Latino women. Gynecologic Oncology, 112, 577–582. Weinstock, H., Berman, S., & Cates, W. (2004). Sexually transmitted diseases among American youth: Incidence and prevalence estimates. Perspectives of Sexual and Reproductive Health, 36, 6–10. World Health Organization. (2012). Cervical cancer. Retrieved from http://new.paho.org/hq/index.php?option=com_con tent&view=category&layout=blog&id=3595&Itemid=3637 &lang=en
Wu, J. P., Porch, E., McWeeney, M., Ohman-Strickland, P., & Levine, J. (2010). Knowledge and concerns related to the human papillomavirus vaccine among underserved Latina women. Journal of Lower Genital Tract Disease, 14(3), 155–161. Yeganeh, N., Curtis, D., & Kuo, A. (2010). Factors influencing HPV vaccination status in a Latino population; and parental attitudes towards vaccine mandates. Vaccine, 28, 4186–4191. Zimet, G. D. (2006). Understanding and overcoming barriers to human papillomavirus vaccine acceptance. Current Opinion in Obstetrics and Gynecology, 18(1), s23–s28. Acknowledgments. This research was made possible with support from the University of the Sciences, Faculty Summer Research Support (RFP-SS-09). MR owes tremendous thanks to Dr. Carlos Juan Crespo for his guidance and mentorship, who had the idea to explore attitudes about the HPV vaccine among Hispanic parents. We owe deepest thanks to “Clara,” who is no longer with us, for her generosity and assistance during the summer of 2009 in North Philadelphia-que Dios te bendiga Clarita. Lastly, we give sincere thanks to all the women who participated in the study. Correspondence regarding this article should be directed to Michelle Ramírez, PhD, MPH, University of the Sciences, Department of Behavioral and Social Sciences, 600 S. 43rd Street, Philadelphia, PA 19104. E-mail: [email protected]
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Acceptability of the Human Papillomavirus Vaccine Among Diverse Hispanic Mothers and Grandmothers Michelle Ramírez, PhD, MPH Amy B. Jessop, PhD, MPH University of the Sciences in Philadelphia Amy Leader, DrPH, MPH Thomas Jefferson University, Philadelphia Carlos Juan Crespo, DrPH, MS Portland State University The human papillomavirus (HPV) vaccine has the potential to reduce rates of cervical cancer and other HPV-related morbidity among Hispanic women who are disproportionately affected by this disease. Understanding the barriers faced by this population is an important public health goal. In this qualitative pilot study, 17 mothers and grandmothers of adolescent girls from diverse Hispanic backgrounds in a large northeastern city in the United States were interviewed to examine attitudes regarding vaccine acceptability. The findings reveal that negative media, concerns about sexuality, side effects, and efficacy may impact vaccine uptake and completion. Of the 4 participants whose daughters had received the vaccine, only 1 had completed the full series, which may speak to the trend of lower series completion among Hispanics. This pilot data could inform important considerations when designing longitudinal research that may provide some necessary insights into the factors that facilitate or impede HPV vaccine completion among U.S. Hispanics. La vacuna contra el virus del papiloma humano (VPH), tiene el potencial de reducir las tasas de incidencia del cáncer de cuello uterino y de otras enfermedades relacionadas con el VPH entre las mujeres hispanas que se ven desproporcionadamente afectadas por estas enfermedades. Comprender las barreras que enfrentan las mujeres hispanas para vacunarse es una meta importante de salud pública. Diecisiete madres y abuelas de niñas adolescentes, de distintos orígenes hispanos residentes en una ciudad del noreste de los Estados Unidos, fueron entrevistadas para examinar sus actitudes relacionadas con la aceptabilidad de la vacuna. Los resultados del estudio mostraron que los mensajes negativos de los medios de comunicación, las preocupaciones acerca de la sexualidad, los efectos secundarios y la eficacia de la vacuna podrían afectar su aceptación y el cumplimiento de los esquemas de vacunación. De las cuatro participantes cuyas hijas habían recibido la vacuna, sólo una había cumplido con la serie completa, lo cual muestra la baja tendencia para completar el esquema de vacunación entre las hispanas. Este estudio piloto proporciona información importante, para diseñar un estudio longitudinal, sobre los factores que facilitan o impiden completar el esquema de vacunación contra el VPH entre las hispanas. Keywords: Hispanics; HPV vaccine; acceptability; qualitative research
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T
States, making HPV the most common sexually transmitted infection (Weinstock, Berman, & Cates, 2004). There are more than 100 types of HPV and roughly 40 types are transmitted sexually (Koutsky, 1997). Approximately 70% of cervical cancers are caused by types 16 and 18, and 90% of genital warts are caused by types 6 and 11 (Parkin & Bray, 2006). National data from Mexican American females showed that roughly one in four females were seropositive for at least one of these four types (Markowitz, Sternberg, Dunne, McQuillan, & Unger, 2009). Two HPV vaccines are licensed for use in the United States and are most efficacious if administered before exposure to HPV through sexual contact; therefore, the Advisory Committee on Immunization Practices (ACIP) recommends routine administration of the HPV vaccine to girls at ages 11 or 12 years (Centers for Disease Control and Prevention [CDC], 2010; Markowitz et al., 2007). Given the recommended age of vaccination, the vaccine’s acceptability to parents and caregivers is a critical issue for research (Garnett, Dubin, Slaoui, & Darcis, 2004; Mays, Strum, & Zimet, 2004; Zimet, 2006). With broad uptake, the HPV vaccine has the potential to reduce the burden of cervical cancer and other HPV-related disease.
he largest Hispanic subgroups residing in the United States are of Mexican, Puerto Rican, and Cuban origin (Hajat, Lucas, & Kington, 2000), and as of July 1, 2011, Hispanics became the nation’s largest ethnic minority (U.S. Census Bureau, 2012). Much of the growth of the Hispanic population is due to immigration from Mexico and other Latin American countries, where cervical cancer rates are among the highest in the world, with mortality rates seven times higher than in North America (Arrossi, Sankaranarayanan, & Parkin, 2003; Chavez, Hubbell, McMullin, Martinez, & Mishra, 1995; World Health Organization [WHO], 2012). In the United States, Hispanic women are diagnosed with cervical cancer almost twice as often as non-Hispanic White women (Downs, Smith, Scarinci, Flowers, & Parham, 2008). Moreover, recent geographic analysis found that Hispanic women experience the highest cervical cancer incidence rates of any racial/ethnic group in every region of the United States. (Watson et al., 2008). This is due, in part, to relatively low rates of cervical cancer screening. Current screening rates range from 71.0% among Hispanics from Central or South America to 77.7% among Hispanics from Puerto Rico, which is less than the 81.4% screening rate for nonHispanic White females (American Cancer Society, 2009). Research has demonstrated that cultural factors may play a role in the underutilization of cervical cancer screening by Hispanic women, in that “embarrassment” and a belief that only women who engage in unwise sexual behaviors need to be screened (Austin, McNally, & Stewart, 2002; Chavez et al., 1995; Harlan, Bernstein, & Kessler, 1991; Martinez, Chavez, & Hubbell, 1997; McMullin, De Alba, Chavez, & Hubbell, 2005; Modiano, 1995). Hispanic women may be equally dubious about health interventions such as the HPV vaccine because of its connection to cervical cancer, a disease apparently infused with culturally-based beliefs regarding appropriate female sexuality. Further, living in the United States may enhance concerns about a daughter’s sexuality among Hispanics. Espin (1997) contends that a daughter’s sexuality becomes a central focus of parental concern among Hispanic immigrants. Whereas Ayala (2006) notes that during the acculturation process, Hispanic mothers often frame sexuality within a discourse of danger, violence, and victimization and express intense concern over their daughter’s vulnerability to male sexuality, as virginity before marriage is still seen as a cultural ideal among many Hispanic groups (Lopez, 2008). Thus, concerns about preadolescent sexual activity can present barriers to HPV vaccine acceptance (Brewer & Fazekas, 2007; Luque, Castañeda, Martinez-Tyson, Vargas, & Meade, 2012).
Successes and Limitations in Vaccinating Hispanic Females Prior research, both in the United States and Mexico, has shown high acceptability rates of the HPV vaccine among Hispanic parents; however, many of the parents in these studies reported concerns about the efficacy of the vaccine, the side effects, and the possibility of it promoting early sexual behavior (Bair, Mays, Sturm, & Zimet, 2008; Lazcano-Ponce et al., 2001; Watts et al., 2009; Wu, Porch, McWeeney, Ohman-Strickland, & Levine, 2010; Yeganeh, Curtis, & Kuo, 2010). The potential for the vaccine to prevent cervical cancer was held in high regard by most parents, who generally agree that the benefits outweigh the risks when deciding whether to get their daughters vaccinated. Despite these positive indicators, Hispanic adolescent females in the United States face several barriers in accessing needed immunizations, which include a lack of stable health insurance and access to a regular health provider (Yeganeh et al., 2010). Although national data report that Hispanic females have higher vaccination initiation rates than their non-Hispanic counterparts (56.2% of females ages 13–17 years old, compared to 45.8% of White and 48.9% of Black females), Hispanic females have lower series completion rates (56.2% compared to 74.7% of White females and 65.4% of Black females; CDC, 2011).
Human Papillomavirus and the Human Papillomavirus Vaccine
Study Purpose This ethnographic-qualitative pilot study was undertaken in a large northeastern city in the United States among ethnically diverse Hispanic parents and grandparents. Ethnographic
Approximately 6.2 million new infections with human papillomavirus (HPV) will occur annually in the United 25
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methods are useful for defining the range and variability of phenomena that are not amenable to numerical measurement or statistical calculation (LeCompt & Schensul, 2010). The researchers’ objectives were to (a) explore general knowledge and attitudes about the HPV vaccine in this population, (b) examine cultural beliefs about female sexual chastity before marriage that may inform vaccine acceptance, and (c) develop hypotheses to be examined in future research. The use of ethnographic methods frame human behavior and belief within a sociopolitical context and use culture as a lens to interpret results (LeCompt & Schensul, 2010). These methods can help researchers and providers understand the sociocultural context that may inform attitudes about the HPV vaccine among Hispanics. Such an understanding may help facilitate the development of culturally appropriate educational and behavioral interventions aimed at increasing vaccination rates among Hispanic females, a population disproportionately burdened by cervical cancer.
Materials Consent forms and interview guides were translated from English to Spanish by a professional translation service. A semistructured interview guide was used as it is the most suitable instrument when the researcher has only one opportunity to interview a participant (Bernard, 2000). Participants received a $20 gift card thanking them for their participation. The study protocol received Human Subjects approval from the University of the Sciences’ Institutional Review Board.
Sample Determining sample size in qualitative, ethnographic research differs from that of quantitative research, in that there are no standardized power calculations available to make sample size determinations. There are, however, useful frameworks created by scholars working in the field of qualitative research that can guide decisions about sample size. Kuzel (1999) demonstrates that 5 to 8 sampling units will suffice for a homogeneous sample. However, several others note that 12 to 20 are commonly needed when looking for disconfirming evidence, or when trying to achieve maximum variation. Maximum variation occurs when a researcher seeks to obtain the broadest range of information and perspectives about a particular area of inquiry (Lincoln & Guba, 1985). By looking for this broad range of perspectives, the investigator is purposefully challenging her preconceived understandings of the phenomenon under study, which can also mitigate against the tendency to make the “messiness” of reality appear “neat and tidy” (Kuzel, 1999). Because this was a pilot study seeking maximum variation, the first author interviewed 16 Hispanic mothers and 2 grandmothers of adolescent girls. Grandmothers were not excluded because they were the primary caretakers of an adolescent girl and have been found to have significant influence regarding health and household decisions among Hispanic families (Allen et al., 2012). One participant was ineligible, as her daughters fell outside of the age specifications for the study, yielding a total of 17 participants.
Methods Setting and Recruitment This study was conducted in a predominantly Hispanic neighborhood (population approximately 45,000; 64% Hispanic), whose residents are mainly from Puerto Rico with a growing Dominican population. This is one of the poorest, underserved areas in the city with 41% of the population younger than 18 years of age, 53% with income less than 100% poverty level, and just 28% of adults with a high school diploma (University of Pennsylvania, Philadelphia Neighborhood Information System, 2012; U.S. Census Bureau, 2010). A local social service agency in the neighborhood agreed to support the primary investigator (MR) with office space to conduct interviews. MR also received recruitment guidance from community consultants working in the agency. Flyers in both English and Spanish describing this study were placed in strategic locations at the agency and in the windows of local businesses. Mothers and grandmothers who were the primary caretakers of adolescent and preadolescent daughters (ages 8–17 years) were purposively recruited by community outreach workers and by the primary investigator. To increase the social and ethnic diversity of the sample, we also recruited participants at a small outdoor health and informational fair sponsored by a local church, where MR sat at a table with information regarding the HPV vaccine and flyers describing this study. Thus, participants were recruited via word of mouth and snowball sampling by MR and a community outreach worker. When using the snowball sampling method, participants often lead the investigator to other research participants based on a designated set of criteria (Trotter & Schensul, 2000); in this case, other Hispanic parents with adolescent daughters.
Interviews and Data Analysis Participants were interviewed in English or Spanish by the primary investigator, depending on the language preference of the participant. Nine interviews were conducted in Spanish and 8 were conducted in English. MR conducted the interviews in the administrative offices in the social service agency, a family business, the outdoor fair, participant homes, and at a local church. Interviews were tape recorded on all but one occasion where the participant preferred not to be recorded. The interview began by asking participants what they knew about the HPV vaccine. If the parent had no knowledge of the vaccine, the interviewer explained that the 26
Acceptability of the HPV Vaccine
TABLE 1. Participant Demographics
vaccine is administered to prevent both cervical cancer and genital warts, and that it is administered in three doses over a 6-month period and is recommended for girls ages 11–12 years. On some occasions, parents would initiate a discussion about sexuality concerns regarding the vaccine. On other occasions parents were asked, “Some parents think getting their daughters vaccinated with the HPV vaccine would encourage sexual activity, how do you feel about this?” At which point the parent would then discuss their views regarding the HPV vaccine and sexuality. At the time of this study, the vaccine had not yet been approved for boys, thus, the study questions focused on parental attitudes about the vaccine for girls. Interview data and field notes were transcribed and analyzed by the primary investigator in an iterative manner using an ethnographic, inductive approach where analysis was informed by themes identified in the literature and by the primary investigator’s personal reading of the data (Gregg, 2011). The primary investigator is a bilingual/bicultural medical anthropologist with significant expertise interviewing women regarding sensitive health matters, therefore, she took the lead in analyzing the data (Ramirez, 2006; Ramirez et al., 2009). She consulted with the coauthors about key methodological issues as they arose regarding sample size, sample composition, and neighborhood characteristics. Three of the four authors discussed coding disagreements and came to a consensus on the most appropriate way to describe neighborhood characteristics and vaccine status. Data were analyzed repeatedly as new themes and subthemes were identified (Higgins, Hirsch, & Trussell, 2008; Ryan & Bernard, 2000). MR hand coded interviews identifying themes and subthemes that captured participants’ attitudes about the HPV vaccine. The case studies and examples presented in this article were selected because they represent the typical patterns that emerged during the interviews.
Characteristic Age (years) Range Average Relationship Mother Grandmother Ethnicity Puerto Rican Dominican Mexican Mexican/Costa Rican Puerto Rican/Non-Hispanic White Marital status Married Cohabitating Separated Single Not available to researchers Language preference English Spanish Education Some primary Primary completed Some high school Some high school and vocational training High school completed Some college College completed (in country of origin) Employment Unemployed Employed Certified nurse assistant Family business House cleaning Social worker Customer service representative Retired Country of birth United States Outside United States Length of time in United States 1–5 years 6–10 years More than 10 years Entire life
Results Most of the participants were Puerto Rican, although other Hispanic groups were represented. Half of the participants were unemployed, receiving some form of government assistance, either supplemental social security income or welfare. Three out of the 17 had professional, servicesector jobs, and two women were retired (one from teaching, the other from house cleaning). All participants had health insurance—either employer-based programs or Medicaid/Medicare programs. Ten women had not completed high school, but 2 out of the 10 had completed vocational training where a high school degree was not required. Four women had completed high school, one was currently enrolled in an online legal studies program that would eventually lead to a bachelor’s degree, and three had completed a university degree in their country of origin. Table 1 displays participant demographics. 27
Number 26–76 30 15 2 11 2 1 2 1 6 2 3 2 4 8 9 1 2 4 2 4 1 3 8 1 3 1 1 1 2 11 6 1 3 5 8
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that it was a preventive vaccine. The mother then asked her 16-year-old daughter what she wanted to do, and the daughter agreed to get the vaccine; at the time of the interview, the daughter was only missing the third shot. Two other Puerto Rican mothers, both of whom had graduated from high school, noted that the reason they had initiated the vaccine for their daughters was to protect them against cervical cancer. One noted a family history of cancer and had initiated the vaccine series for her daughter in Puerto Rico and was hoping to get the third injection in the United States. The other participant had been diagnosed with cervical cancer and her daughter had received the complete series. A familial and personal experience with cervical cancer motivated these women to get their daughters vaccinated to protect them against the disease. A Mexican immigrant woman, college educated in Mexico, reported that her mother died of cervical cancer. This participant had also received treatment for early stage cervical cancer, thus like the Puerto Rican mothers mentioned earlier, she also wanted to protect her child from this disease. This woman’s daughter had received the first two shots; however, at the time of the interview, the daughter was outside of the recommended 6-month window for the third dose. She said that at her daughter’s next physical, she would ask about the third dose. Amidst our discussion, she mentioned concerns about immigration issues and side effects related to the HPV vaccine. She had been hearing through various Spanish language media that the vaccine was mandatory for individuals seeking legal residency, which was creating quite a stir in the Mexican immigrant community. She mentioned that it was not fair to obligate immigrants to receive the vaccine while allowing citizens to make their own decisions about it. She also noted that she was afraid of the potential side effects that she heard about. However, a friend from Puerto Rico assured the participant that her daughter had received the full series and was not suffering any ill effects, thus encouraging the participant to make sure her daughter received the final dose of the vaccine. Vaccination Not Initiated. Many of the parents in this category had limited knowledge about the HPV virus and vaccine and were unaware that HPV is sexually transmitted. Some had heard about the vaccine and its connection to cervical cancer but did not know that it also prevents most strains of genital warts. After the brief description was provided, the mothers expressed positive views about it; however, concerns were also expressed. Major subthemes guiding positive attitudes toward the vaccine were once again—fear of cancer, protecting their daughter against cancer, and physician recommendation. Although the vaccine was found to be acceptable by all parents, there were concerns expressed about vaccine efficacy, potential side effects, and cost. And although sexuality did not appear to be a central concern regarding vaccine acceptance, the issue came up in interesting ways.
Categories and Themes Because the study sought to achieve maximum variation regarding attitudes among Hispanic parents, individuals were recruited regardless of their daughter’s vaccine status. Thus, the first major category or theme to emerge within the sample was—parents whose daughters had received the vaccine, those parents whose daughters had not received the vaccine, and one parent who was unsure about whether the vaccine her daughter received was the HPV vaccine. We are calling these three categories: (a) vaccine initiated (n 5 4), (b) vaccine not initiated (n 5 12), and (c) unsure of vaccine status (n 5 1). Among the vaccine initiates, three parents were in the process of getting their daughters vaccinated; their daughters had received two of the three shots; however, only one girl had received the full series. The remaining 12 mothers and grandmothers had not initiated the vaccine for their daughters/granddaughters. Within the three vaccine status categories, two themes arose regarding vaccine acceptance and vaccine concerns. The subthemes listed in Table 2, under acceptance and concern, are perspectives and experiences that appeared to promote vaccine acceptance or vaccine concern. Discussions about vaccine acceptance and vaccine concerns are discussed in the following text within the category of vaccine status, which further reveals the complexity of HPV-vaccine acceptance. For example, even when a parent initiated the series for their daughters, some continued to express various concerns about it. Moreover, many of the subthemes overlapped within the course of a conversation with a participant, thus, rather than extracting quotes to provide thematic exemplars, we are providing a more naturalistic representation of how the parents discussed their opinions and concerns about the HPV vaccine; we feel that the conversational and ethnographic context more accurately capture parental attitudes. Vaccine Initiated. One college-educated, Puerto Rican mother who was recruited at the health fair, a selfdescribed devout Christian, noted that at first she was concerned about the vaccine’s implications regarding her daughter’s sexuality but was told by her physician
TABLE 2. Coding Themes and Subthemes Themes Vaccine Acceptance
Vaccine Concerns Subthemes
Physician recommendation
Sexuality
Protection against cancer
Side effects
Fear of cancer
Immigration
Family/personal experience with cancer
Efficacy Cost 28
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Two Puerto Rican mothers, who were born in the continental United States, expressed positive attitudes regarding the vaccine but were unsure about its efficacy and side effects. One mother said that she was, “A little scared cuz’ I don’t know like, the side effects of it, or if it really does prevent it [cervical cancer]” while the other noted that she had heard from her cousin that the vaccine helped her “fight off” cancer, so she was going to ask her doctor whether or not the vaccine actually prevents cancer. A Mexican American mother with a 10th-grade education seemed very unsure about whether or not to get her daughter vaccinated. This participant had actually been diagnosed with early stage cervical cancer for which she had received treatment and described the process as “very stressful” and wanted to protect her daughter from going through a similar ordeal. However, she had also heard in the news that there are side effects associated with the vaccine and was conflicted about whether or not to get her daughter vaccinated. Furthermore, her husband was not in favor of the vaccine because he believed that it would promote early sexual activity. She also expressed concern about a vaccine that would allow her daughter to think that she could have sex without “getting diseases.” Her approach to this dilemma was to not tell her daughter what the vaccine was for: “I wouldn’t tell her, I would just get it like a regular shot and then when she’s older, I’ll let her know when she’s already active, I wouldn’t like the doctor to lecture her.” This mother further noted that if she did decide to get her daughter vaccinated, she would not tell her husband, “I’m the one who takes her to the doctor, so he doesn’t have to know. It’s up to me, it would be down to me in the end.” A 66-year-old Puerto Rican grandmother, who was college educated in Puerto Rico and is the full-time caretaker of her granddaughter, actually knew quite a bit about the vaccine and stated, “I am convinced that it is necessary.” For this participant, cancer is a disease like any other disease such as tetanus or polio for which you can be vaccinated, thus the HPV vaccine should not be connected to sexuality. However, she noted that “a lot of people don’t believe this because they have the taboo that giving the vaccine to the girl is giving her permission to freely have sex.” This woman’s granddaughter had lived with her from the age of 2–11 years in Puerto Rico because the girl’s mother died. The participant’s son (the girl’s father) remarried and moved to Chicago, at which point, the girl moved back in with her father and stepmother and lived with them from age 11 to 15 years. However, because of familial conflicts, the granddaughter chose to live with her grandmother again and has been living full time with the participant for the last year and a half. This brief residence history is germane because the participant was convinced that the reason why her granddaughter had not received the HPV vaccine was because of her son’s more traditional way of thinking. She noted that “men have a different point of view” because her son’s father (her ex-husband)
was someone who believed you should not talk to your children about sex and was convinced that her son had the same perspective, therefore had not initiated the vaccine for his daughter. Now that her granddaughter was living with the participant, she was going to speak to the girl’s doctor about getting her vaccinated. An unmarried, 28-year-old Puerto Rican woman with a ninth-grade education was the mother of six children. At first, it appeared that she had very little knowledge about the HPV vaccine, but during the brief description, she remembered she had read that the virus caused cervical cancer from materials that accompanied a douching product. This participant was unclear about the precise cause of HPV so MR explained that it was sexually transmitted. After the description, MR asked the participant how she would feel about vaccinating her daughter, at which point she stated, “It would be great, cuz’ I don’t want her to get no kind of disease.” MR asked if she believed that the vaccine would promote sexual activity to which the participant replied: No I don’t think so . . . maybe women have to talk about it more. I’m not giving her permission to be sexually active but you know just in case because I can’t stop her . . . she could probably do it behind my back, but I will talk to her about it . . . Every woman would wish that they could wait till they’re married, but that’s not gonna happen. It depends on how they’re growing, on the parents, on the relationship with their mother and daughter.
This mother articulates a wish that “every woman” would want for themselves and their daughters—the cultural ideal of chastity before marriage, but seems to believe that it is unlikely to be upheld. Therefore, it is important for mothers to be realistic and to have the kind of relationship with their daughters where they can openly discuss issues related to sexuality. A college educated, Evangelical, U.S. born Dominican woman, was the mother of seven children, five of whom were girls aged 20, 17, 11, 9, and 7 years, had heard very little about the HPV vaccine prior to the interview. After the description, the participant noted that she would like to have her daughters vaccinated given that “cancer is a very scary word” and was concerned about protecting her children, and also noted, “I don’t care about the sex part, I care about protecting my kids, since there’s no cure, might as well prevent it.” This mother also commented that she believes that Hispanics who do not have much education might be more inclined to worry about the vaccine’s connection to sexuality. She also mentioned that her experience as a customer service representative for an insurance company has made her more aware of the high prevalence of cancer among women, which she noted might also make her more inclined to accept the HPV vaccine for her daughters. Although this mother seemed very positive about the vaccine’s ability to prevent cervical cancer, follow-up research would be necessary to see if she has indeed initiated the vaccination process for any of her daughters. 29
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a sixth-grade education did not know the name of the vaccine her daughter had just received but still wanted her daughter to be protected against cervical cancer. Hispanics have the lowest educational attainment levels of all ethnic groups in the United States (The White House, 2011) and may require additional efforts on the part of providers to make sure Hispanic parents are indeed making informed decisions about childhood vaccines (VanSlyke et al., 2008). However, providers should not necessarily assume low educational levels even if their Hispanic patient is monolingual. Three women in this study were college educated; two were educated in their home countries and were monolingual. Interestingly, the college-educated Mexican woman faced a much different social reality in her decision making about the vaccine. At the time of the interview, this woman’s daughter had received the first two injections of the series but was unsure about whether or not the vaccine was mandatory for legal residency. According to Section 212 of the Immigration and Nationality Act (INA) immigrants who wish to be lawfully admitted to the United States were mandated to receive vaccinations against vaccine-preventable diseases recommended by the ACIP. At the time this study was undertaken, the mandate also applied to the HPV vaccine. However, Puerto Ricans, even if they are immigrants, are also American citizens; therefore, this temporary law would not have applied to them. The HPV vaccine mandate has since been rescinded, but at this particular moment in the vaccine’s social history, there was a different decision making playing field for different Hispanic groups regarding HPV vaccine. Thus, providers and policy makers should be attuned to different political-economic realities among different Hispanic groups that may inform vaccine uptake and completion (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005). Also, germane to the current discussion is the Mexican mother’s mention of a friend whose daughter had received all three doses of the HPV vaccine and was not experiencing any adverse side effects, thus encouraging the participant to do the same—possibly suggesting a role for lay, or peer health advisors in vaccine completion. Another concern articulated by several mothers in this study was related to the vaccine’s potential side effects. Again during the summer of 2009, the HPV vaccine received a great deal of negative media attention. A front-page article in a local weekly newspaper was titled, “Risky Business: One Teen says Gardasil Wrecked Her Life” (Murtha, 2009). The article followed the story of an 18-year-old young woman named “Victoria” who reportedly suffered nonepileptic seizures, migraines, and fainting spells in addition to many other severe symptoms; all of which she and her mother attributed to receiving the second dose of Gardasil. Negative media attention may indeed confound decision making for parents: A Texas study found that parental concerns about vaccine safety and
Finally, an Evangelical grandmother from the Dominican Republic stated, “I think it’s very important to avoid cancer” and did not believe that it would promote sexuality in her granddaughter because her granddaughter is also Christian, but then also added that “there is no money for it, it is a little bit expensive.” Unsure of Vaccine Status. A Puerto Rican mother, who was unsure about the vaccine her 12-year-old daughter had just received, has lived in the United States her entire life and has a sixth-grade education. This mother echoes the desire to protect her daughter from cancer and discusses a familial history of cervical cancer: She got her last shot at 12, but I’m not too sure if it was this one, I don’t remember him telling me the name. I would like it, I would like for her to get it, you know, if it’s going to help for her future, I would love to have her protected. My mom had cervical cancer . . . so it runs in my family genes.
Discussion Although most participants did not cite sexuality as a barrier to vaccine uptake, concerns or reflections about sexuality did appear in some of the discussions. One mother noted that sexual chastity before marriage, although desirable, was unlikely, thus it may be necessary for mothers to talk openly with their daughters rather than assuming they will not be sexually active. For others, such concerns were overridden by the importance of cancer prevention and physician recommendation. Although, one mother did not want a physician lecturing her daughter about what the vaccine is for, which highlights once again potential complexities attached to STI vaccines. This participant, along with one of the grandmothers interviewed, perceived that male family members are concerned about the HPV vaccine’s connection to female adolescent sexuality, highlighting possible gender differences among Hispanic men and women and their beliefs about the HPV vaccine. One mother noted, however, that it would be her decision “in the end,” because she is the one who takes her daughter to the doctor. Among the vaccine initiates, only one daughter out of the four had completed the three-dose series, which may be a reflection of the overall lower series completion rates among this population (CDC, 2011) but is noteworthy for the following reasons: All of the participants in this study had some type of health insurance and did not report difficulty obtaining medical care. Second, this study was conducted in a city nationally recognized for its childhood vaccine delivery programs; therefore, there may be host of political, economic, and sociocultural factors that interfere with HPV vaccine completion. What is also potentially noteworthy about the findings from this small pilot study is the diversity of experiences based on factors such as education, ethnicity, and immigration status. A Puerto Rican mother with 30
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negative media were the most commonly encountered barriers to vaccine uptake (Kahn et al., 2009). Moreover, the HPV vaccine has had its share of media controversy— consider the more recent claims made by former U.S. presidential Republican candidate Michele Bachmann (Pearson, 2011). Thus at any given time, providers may need to be aware of the media messages generated about the HPV vaccine and may have to reassure parents that the vaccine is indeed safe and efficacious, as concerns also emerged regarding the efficacy of the vaccine. The frequency with which either a personal or familial experience with cervical cancer was discussed continues to remind medical providers and researchers of the burden this disease has on Hispanic women. It could be that women interested in participating in this study selfselected because of a personal or familial experience with cervical cancer; however, not all women who participated knew or understood the purpose of the vaccine. The mothers who initiated the series for their daughters all wanted to protect them from cervical cancer, particularly if there is a family history of cervical cancer. Therefore, the impact of cancer prevention should be highlighted when providing education about the HPV vaccine to Hispanic parents. Indeed, research has shown that although concerns about adolescent sexuality can negatively affect HPV vaccination intention among Hispanics, belief in illness prevention and physician recommendation may positively affect vaccine intention (Luque et al., 2012).
to receiving preventive care that address this health disparity—such as the HPV vaccine—are important for providers and policy makers to address in a culturally competent manner. In this small pilot study, concerns about adolescent sexuality and side effects persist about the HPV vaccine. However, these concerns can be overcome via provider recommendation. Future research could examine whether gender differences exist among Hispanic parents regarding attitudes about the HPV vaccine and whether more socially conservative male attitudes affect vaccine uptake and completion. Also suggested by this pilot project is examining the role that peer support can play in HPV vaccine uptake and completion. Education and outreach for the vaccine may also need to be attuned to various political-economic differences among Hispanic parents and negative media attention that can confound decision making. Further, aggregated statistics that present Hispanic health as a single unified category may belie a host of social and political differences within this ethnic group that may inform health decision making. Lastly, data have shown that although Hispanic parents are not less likely to initiate the vaccine, Hispanic girls are less likely to have completed the series; thus, more research, preferably a longitudinal study design, is necessary to determine the precise political, economic, and socio cultural factors that inform vaccine completion.
References Limitations
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Qualitative methods capture diversity and complexity, however, cannot be used to make generalizations about populations. This was a small and diverse sample of Hispanic mothers and grandmothers in an urban northeastern region of the United States. Hispanic parents in rural regions of the United States or agricultural workers may have very different views about the HPV vaccine. However, urban centers are important to consider because this is where a great deal of population growth is occurring and diversifying. The primary investigator consulted with key members of the team regarding methodological and thematic issues as they arose; however, she conducted most of the analysis and interpretation of results, therefore, reflect her observational and analytical biases. Although these findings may not be generalizable, they can be understood as important first steps to developing hypotheses to be examined and tested in future research.
Conclusions and Recommendations Considering that Hispanics are the fastest growing minority in the United States and that Hispanic women are disproportionately burdened with cervical cancer, barriers 31
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Wu, J. P., Porch, E., McWeeney, M., Ohman-Strickland, P., & Levine, J. (2010). Knowledge and concerns related to the human papillomavirus vaccine among underserved Latina women. Journal of Lower Genital Tract Disease, 14(3), 155–161. Yeganeh, N., Curtis, D., & Kuo, A. (2010). Factors influencing HPV vaccination status in a Latino population; and parental attitudes towards vaccine mandates. Vaccine, 28, 4186–4191. Zimet, G. D. (2006). Understanding and overcoming barriers to human papillomavirus vaccine acceptance. Current Opinion in Obstetrics and Gynecology, 18(1), s23–s28. Acknowledgments. This research was made possible with support from the University of the Sciences, Faculty Summer Research Support (RFP-SS-09). MR owes tremendous thanks to Dr. Carlos Juan Crespo for his guidance and mentorship, who had the idea to explore attitudes about the HPV vaccine among Hispanic parents. We owe deepest thanks to “Clara,” who is no longer with us, for her generosity and assistance during the summer of 2009 in North Philadelphia-que Dios te bendiga Clarita. Lastly, we give sincere thanks to all the women who participated in the study. Correspondence regarding this article should be directed to Michelle Ramírez, PhD, MPH, University of the Sciences, Department of Behavioral and Social Sciences, 600 S. 43rd Street, Philadelphia, PA 19104. E-mail: [email protected]
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