Motivators and Barriers to HPV Vaccination: A Qualitative Study of Underserved Women Attending Planned Parenthood

"Healthcare providers are optimally positioned to fill the gap in prior missed vaccine opportunities and empower women by recommending HPV vaccination."

Human papillomavirus (HPV) vaccination among medically underserved adult women in the United States (US) is low, and yet HPV-associated cervical cancer disproportionately impacts low-income individuals and women of colour. This study aimed to identify multi-level factors that reflect broader individual and structural motivators and barriers to HPV vaccination among medically underserved women using the Planned Parenthood of Southeast Pennsylvania (PPSP) safety net health centre.

The goal of interviewing women attending PPSP was also to inform the adaptation of a National Cancer Institute (NCI) evidence-based cancer control programme (EBCCP). The original video-based intervention was grounded in the HPV vaccine decision stories of college women. With the goal of adapting the intervention to reflect decision stories from medically underserved women, the researchers intentionally collaborated with Planned Parenthood, whose centres are often situated in underserved and under-resourced communities. In the adapted intervention, decision stories were meant to be delivered on a health kiosk placed in the waiting rooms of health centres.

Guided by narrative engagement theory, 24 qualitative interviews elicited HPV vaccine decision stories from both vaccinated and unvaccinated young adult women attending a PPSP health centre between June 18 to July 16 2015. Using an iterative data analysis approach, the researchers identified three motivators to vaccinate against HPV:

• Receiving an explicit vaccine recommendation from a healthcare provider (a structural determinant) - Prior to vaccination, most women described having limited awareness about HPV and/or the vaccine. Some women attributed prior vaccine awareness to television commercials, health centre posters, conversations at school, and discussions with friends, family, or co-workers. However, overall, many women reported learning about the vaccine through recommendations and conversations with their healthcare provider.
• Feeling empowered to take control of one's health (an individual determinant) - Participants explicitly discussed taking charge of their sexual and reproductive health by vaccinating.
• Knowing someone infected with HPV (an individual determinant) - Knowing someone with HPV was cited as a motivator to learn more about the vaccine.

Among unvaccinated participants, barriers to HPV vaccination included:

• Not receiving an explicit vaccine recommendation from a healthcare provider (a structural determinant) - Approximately half of unvaccinated participants reported not receiving a recommendation, which they said placed a burden on them.
• Low perceived risk for acquiring HPV or that HPV is not severe (an individual determinant) - For instance, a few women did not perceive the vaccine as necessary because they were not sexually active when a recommendation was given.
• Lack of maternal support to vaccinate (a structural determinant) - For example, one participant recalled that despite her willingness to vaccinate and her mother receiving a vaccine recommendation from a healthcare provider, her mother refused to vaccinate her as an adolescent.

Reflecting on the findings, the researchers point to the following, among other considerations:

• The importance of healthcare providers seeing adult women to inquire about their patient's HPV vaccination status during medical appointments - Although paediatric healthcare providers may have recommended the HPV vaccine to women as adolescents, their parents may have declined vaccination. Therefore, for these adult women, asking about and recommending the HPV vaccine ensures that those who missed vaccination have the opportunity to catch up on HPV-associated cancer prevention.
• The intersection of gender, race, and class that may lead medically underserved women to experience powerlessness on multiple levels - In that context, encouraging self-responsibility as a form of sexual and reproductive empowerment may be beneficial. Previous research has found that incorporating empowerment into risk messaging is a persuasive message strategy. Empowerment can also be achieved by ensuring that patients feel heard, respected, and informed when making vaccine decisions with their healthcare provider. This point may be especially salient for populations that have historically and systemically encountered racism and discrimination.
• Low HPV risk perceptions, which were associated with misconceptions around disease severity and the vaccine's utility - Healthcare providers, including gynaecologists, should deliver high-quality HPV vaccine recommendations that are strong and educational, and they should express the urgency to vaccinate. Providers should inquire about prior vaccine awareness and knowledge, as well as desired learning formats, when educating patients. In addition to conveying the morbidity and mortality of HPV-related cancers, providers could highlight the psychological distress associated with acquiring the virus, including genital warts and future partner interactions. Providers can share relational-focused HPV vaccine messages as a strategy to prioritise HPV vaccination.
• The need to remove structural barriers that make medically underserved women less likely to receive HPV vaccine recommendations from healthcare providers - Reported disparities have been associated with inadequate provider engagement, recommendation practices rooted in perceptions and personal judgement rather than guidelines, and provider discomfort discussing sex-related topics. Eliminating these structural barriers - and missed opportunities to vaccinate - is crucial for medically underserved women. Increasing recommendation rates during a wide range of medical visits (e.g., annual check-ups, college vaccination, etc.) ensures that recommendations are made wherever and whenever women present in the medical system.

Eight prototypical vaccine decision narratives from this study were translated into four scripts and then delivered via a health kiosk in the PPSP waiting room.

In conclusion: "The themes uncovered in this study reveal the need to disseminate vaccine messages that address multi-level factors to vaccination and speak to not only individual knowledge but also to HPV risk perceptions, empowerment, protecting one's health, family support, and trusted healthcare provider recommendations.....Additional research is needed to not only identify additional multi-level motivators and barriers to vaccination, but to determine how to leverage this information to create effective and empowering HPV vaccine messages that resonate with medically underserved women."