|ORIGINAL RESEARCH PAPER
|Year : 2011 | Volume
| Issue : 3 | Page : 479
Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability
E Kobetz1, J Menard2, G Hazan2, T Koru-Sengul1, T Joseph1, J Nissan1, B Barton2, J Blanco2, J Kornfeld3
1 University of Miami, Miller School of Medicine, Miami, Florida, USA
2 University of Miami, Sylvester Comprehensive Cancer Center, Division of Cancer Prevention and Control, Miami, Florida, USA
3 National Cancer Institute, Coastal Cancer Information Service (CIS), Coral Gables, Florida, USA
|Date of Submission||29-Apr-2010|
|Date of Acceptance||11-May-2011|
|Date of Web Publication||08-Dec-2011|
University of Miami, Miller School of Medicine, Miami, Florida
Source of Support: None, Conflict of Interest: None
Introduction: Women in Haiti and throughout the Haitian Diaspora shoulder a disproportionate burden of cervical cancer morbidity and mortality. The widespread Human Papillomavirus (HPV) vaccination holds promise for helping to attenuate this disparity. However, previous research has not fully examined Haitian women's perceptions of, and barriers to, HPV vaccination, which is essential for informing future intervention. The current paper aims to fill this gap.
Methods: As part of ongoing Community-Based Participatory Research (CBPR) efforts, we conducted a series of focus groups with Haitian immigrant women in Little Haiti, the predominantly Haitian neighborhood in Miami, Florida, U.S. Focus group questions assessed women's knowledge and beliefs about cervical cancer and HPV, their opinions of vaccines in general, their knowledge and perceptions of the HPV vaccine specifically and health communications preferences for cervical cancer prevention.
Results: Among the participants who had heard of HPV, many held misconceptions about virus transmission and did not
understand the role of HPV in the development of cervical cancer. Virtually all participants expressed support for vaccines in general as beneficial for health. Some women had heard of the HPV vaccine, primarily as the result of a contemporary popular media campaign promoting the Gardasil; vaccine. Physician recommendation was commonly mentioned as a reason for vaccination, in addition to having more than one sex partner. Women felt the HPV vaccine was less appropriate for adolescent girls who are presumed as not sexually active. Women indicated a strong preference to obtain health information through trusted sources, such as Haitian physicians, Haitian Community Health Workers, and especially Kreyol-language audiovisual media.
Discussion: Study findings indicate a need for culturally and linguistically appropriate educational initiatives to promote awareness of HPV and its role in cervical cancer, the importance of vaccination against the virus, explicitly differentiating HPV from HIV and providing specific information about vaccine safety.
Conclusion: In the U.S., there is a substantial lack of educational information available in Haitian Kreyol about HPV and cervical cancer. This gap results in missed opportunities to promote disease prevention through vaccination and regular screening. Addressing such gaps is essential for achieving health equity among Haitian immigrant women and other, similarly underserved women, who are disproportionately burdened by cervical cancer.
Keywords: Community-based participatory research (CBPR), Human Papillomavirus (HPV), immigrant women
|How to cite this article:|
Kobetz E, Menard J, Hazan G, Koru-Sengul T, Joseph T, Nissan J, Barton B, Blanco J, Kornfeld J. Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability. Educ Health 2011;24:479
|How to cite this URL:|
Kobetz E, Menard J, Hazan G, Koru-Sengul T, Joseph T, Nissan J, Barton B, Blanco J, Kornfeld J. Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability. Educ Health [serial online] 2011 [cited 2017 Sep 21];24:479. Available from: http://www.educationforhealth.net/text.asp?2011/24/3/479/101428
In the United States, cervical cancer disproportionately affects racial/ethnic minorities, foreign-born and medically underserved women1-4. In South Florida, disease incidence is highest among Haitian women, particularly those who are recent immigrants and those who reside in Little Haiti, a large ethnic enclave in the Miami metropolitan area. Between 2004-2007, the estimated incidence of cervical cancer for this enclave was 38/100,0005. This rate is more than four times higher than that reported for Florida generally (8.8/100,000) and for Black women specifically (10.7/100,000) during the same time period6. This disparity primarily reflects underutilization of regular Pap smear screening, the best method available for prevention and early detection of disease7,8. Haitian women face multiple barriers to routinely accessing the formal healthcare system, particularly at the intervals recommended by cancer preventive guidelines9-11. Thus, for this population sub-group, vaccination against Human Papillomavirus (HPV) infection, the principal cause of cervical cancer12, may offer an effective strategy for disease prevention13.
Presently, more than 150 types of HPV have been identified, of which 40 are sexually transmitted14. Low-risk types six and 11 are the most common cause of benign genital warts; whereas, high-risk strains 16 and 18 are responsible for approximately 70-75% of all cervical cancers, as well as cancers of the vulva, vagina and penis14,15. Condoms do not completely protect against HPV infection as the virus is easily transmitted through genital contact16. HPV infection is very common in the population at large, has no identifiable symptoms, and typically clears on its own. Persistent infection with high-risk virus types is associated with carcinogenesis17.
Currently, the U.S. Food and Drug Administration (FDA) has approved two vaccines to protect against persistent HPV infection associated with disease onset. Gardasil® was the first of such vaccines to be approved, in 2006. As a quadrivalent vaccine, it offers protection against four types of HPV, including the two types most commonly associated with genital warts (types six and 11) and the two types responsible for most cervical cancers (types 16 and18). The other vaccine, Cervarix®, was approved by the FDA in 2009. As a bivalent vaccine, it protects against HPV types 16 and 18. Current epidemiologic evidence indicates that both vaccines demonstrate some degree of cross-protection against other similar HPV types, such as 31, 33, and 45 which also have the potential to cause cervical cancer18,19. The vaccines do not protect against all forms of HPV, but they demonstrate high protection against persistent infection with the most common cancer-causing HPV types.
Presently, the FDA has approved Gardasil® for use with females aged nine to 26 years, and Cervarix® is FDA-approved for females aged 10 to 25 years. Gardasil® was also recently approved for use with males aged nine to 26 years, primarily for the prevention of genital warts. These age ranges are based upon safety and efficacy studies and reflect the ideal time period within which vaccination would be most beneficial. Each vaccine requires a series of three injections, which should be completed within six months. The U.S. Centers for Disease Control and Prevention currently recommends that vaccination should begin in females by age 11 to 12 years, with the second injection approximately eight weeks after the first, and the third, and final, injection to be given six months following the first injection15. For greatest efficacy, the HPV vaccination series should be completed prior to sexual debut.
In spite of the benefit of reduced cervical cancer, HPV vaccination remains controversial in the U.S. Barriers to vaccine participation include parental concern about promiscuity with HPV vaccination, concern about vaccine safety and vaccine cost20-24. Existing published studies reveal that HPV vaccine knowledge, awareness and acceptability vary between women of diverse ancestry and English language proficiency25,26. To our knowledge, previous research has not explicitly examined HPV vaccine acceptability among women of Haitian descent. This paper helps address that gap. As part of an ongoing, community-based cancer control initiative in Little Haiti, we conducted a series of focus groups with Haitian immigrant women to understand factors that may impede or enable vaccine uptake. Study findings will inform the development of a culturally responsive intervention to promote vaccine use within Little Haiti and other Haitian enclaves in the United States and abroad.
Materials and Methods
Community-based Participatory Research (CBPR)
The current study was conducted in 2010 as part of an ongoing Community-based Participatory Research (CBPR) initiative in Little Haiti. CBPR is a research methodology, increasingly popular in the field of public health, which invites community participation throughout the research process, from study conceptualization to dissemination of findings27-29. Accordingly, CBPR reflects, and is often grounded in, community members’ socio-cultural orientation to health and disease prevention, their language preferences and literacy levels28. This approach helps dissuade community suspicion about the intent of inquiry, which is prevalent in Little Haiti.
Overview of Patnč en Aksyon
In Little Haiti, CBPR efforts are governed by a campus-community partnership known as Patnč en Aksyon (Partners in Action). This partnership involves active participation of community leaders from Little Haiti, as well as an interdisciplinary team of investigators from a large university in the Miami metropolitan area29. Health priorities were first elicited from Little Haiti residents at the inception of this community-academic partnership in 2004; the prevention of cancer emerged as a top concern. Women in Haiti and the Haitian Diaspora are heavily affected by cervical cancer, which is highly preventable and treatable with routine Pap screening and timely follow up for detected abnormalities.
Accordingly, the partnership’s ultimate goals are to reduce the excess burden of cervical cancer experienced by Haitian women and to improve the health status of Little Haiti, more generally. For the focus group research described here, community and academic partners worked collaboratively to develop the focus group guide, giving equal privilege to divergent perspectives regarding study questions of interest, and how to best ask such questions.
Focus group questions were designed to gauge participants’ attitudes towards vaccines generally, and towards Gardasil®, the quadrivalent HPV vaccine, specifically. We asked women about Gardasil® because Cervarix® was relatively new to the market at the time of this study. Participants were much more likely to have heard of Gardasil® due to heavy marketing and promotion of Gardasil® in mainstream media.
Community Health Workers (CHWs) were primarily responsible for recruiting study participants and collecting study data. The CHWs were women of Haitian descent, who speak English and Haitian Kreyol fluently, and are knowledgeable about community norms and cultural mores. They were formally employed by a large community-based organization (CBO), whose leadership is active in Patnč en Aksyon and well-respected throughout Little Haiti.
This study was vetted and approved by our university Institutional Review Board (IRB) and the Patnč en Aksyon Community Advisory Board prior to implementation.
Participant Recruitment and Setting
The CHWs recruited women primarily through the extensive network of the CBO where they were formally employed, and by canvassing community venues across Little Haiti, including flea markets, health clinics and laundromats, to identify women meeting study eligibility criteria. Women were eligible to participate if they self-identified as Haitian, currently lived in Little Haiti, and were between the ages of 21 and 75. We set these age parameters because we were primarily interested in hearing the opinions of adult women in several groups. Specifically we sought those who met the current minimum age recommended for beginning regular Pap screening (i.e., 21 years), those who were age eligible for the HPV vaccine (i.e., up to 26 years), or those who could have children or grandchildren who met the HPV vaccine age eligibility criteria. The focus groups were held at a trusted social service organization located in the heart of Little Haiti over a two-day time period. Five groups were conducted in total, each with approximately eight women, for a total of 41 participants.
Focus Group Procedures
One CHW moderated all five focus groups using the focus group guide, which was designed to explore women’s knowledge of, and perspectives on, HPV, cervical cancer and different domains of HPV vaccine acceptability. In order to minimize influencing women’s responses, participants were first asked if they had heard of HPV and if they knew what it was. After women provided responses about HPV, the CHW briefly explained HPV, taking care to clearly distinguish it from HIV. The CHW followed by asking participants about their familiarity with the HPV vaccine and understanding of its purpose. After hearing responses, the CHW briefly explained that the vaccine protects against HPV infection and is most effective if given before the onset of sexual activity.
The CHW obtained informed consent from each participant prior to initiating group discussion. To address any potential literacy and written language proficiency issues, the CHW read the consent forms aloud to the participants, who then signed the consent form. All participants were also provided with printed copies of the consent forms as well. The groups were conducted in Haitian Kreyol, digitally recorded and then later interpreted and transcribed into English by the CHW. On average, each group lasted two hours. As compensation for their time and contribution to this research, all participants were given a US$ 25 gift card.
For this analysis, we focus on five domains considered significant to understanding issues related to HPV vaccine acceptability within a population of interest30-34. These domains include: 1) general Perceptions of Vaccines; 2) knowledge of HPV; 3) knowledge of HPV Vaccine; 4) perceptions of HPV Vaccine; and, 5) HPV Vaccine Intentions. Our focus group guide assessed these domains and their unique contribution to HPV vaccine acceptance. Table 1 illustrates the questions comprising each domain.
Table 1: Domains of HPV vaccine acceptability
Two researchers independently reviewed the focus group transcripts for emergent themes using a grounded theory approach35,36. The primary purpose of grounded theory is to construct a preliminary framework, rooted in study participants’ lived experiences, that informs understanding of a phenomenon or phenomena in question37.
First, we critically reviewed the data, assigning in-vivo codes, when possible, to emergent themes and sub-themes38. In-vivo codes use women’s own words and phrases, to define and characterize emergent themes and sub-themes, and in so doing, more accurately reflect participants’ perceptions of the phenomena of interest25. Intercoder reliability for open coding was high (k = 0.81, 95% CI 0.67 – 0.94, p<0.0001), indicating a high degree of agreement in the analysis and interpretation of findings between researchers. The two coders discussed any differences in their analyses and came to a consensus about how to best reconcile such variability in the final, combined coding schema.
Upon completing open-coding, we used constant comparison to identify similarities, differences and interrelationships among themes emerging from the response narratives within and across the five focus groups. This process enabled us to develop a conceptual framework to inform understanding of HPV vaccine acceptability among Haitian immigrant women in Little Haiti. While our primary source of data was transcriptions of women’s interview responses, we remained aware of the potential pitfall of inadvertently developing a folk theory based solely on participants’ perceptions. Thus, throughout the analysis process, we compared women’s responses to the CHWs’ field notes, and also to existing literature about vaccine acceptability among other medically underserved populations. Importantly, we also sought to understand such barriers in the broader context of Haitian women’s perceptions of health and illness. By situating an exploration of vaccine acceptability within this context, we were able to better understand how women perceived cancer etiology and disease prevention. A more comprehensive understanding of women’s perceptions within these domains allows for the creation of meaningful health interventions to increase vaccine uptake within this vulnerable population sub-group.
Focus Group Participant Demographics
Table 2 summarizes the demographic characteristics of study participants (n=41). Women ranged in age from 21 to 71, though approximately 34% of the participants were over 50 years of age. A total of 12.2% of participants were, themselves, age-eligible for the HPV vaccine, and although we did not explicitly ask, it can be assumed that approximately 54% had sons or daughters who were age-eligible for the HPV vaccine, based on age-range alone. Most women were not employed in the formal economy, had less than a high school education, and were not married. The majority of study participants primarily spoke Haitian Kreyol and had lived in the U.S. for more than ten years.
Table 2: Socio-demographic characteristics of study participants
Focus Group Findings
Analysis of the focus group transcripts yielded patterns in participants’ responses. Emergent major themes and sub-themes in the study domains were largely consistent across the five focus groups. The following sections detail findings in each study domain.
Domain 1: General Vaccine Perceptions
We assessed women’s perceptions of vaccines in general as a means of understanding their orientation to disease prevention and how such an orientation may influence HPV vaccine acceptance. The majority of women felt highly positive about vaccines and there was a general consensus that vaccines themselves do not cause illness. Participants described immunizations as important, beneficial actions to prevent illness.
'Vaccines are important [and] that [is] why it is mandatory for children.'
'Yes, vaccines can help you not to get sick.'
While most participants felt positive about vaccines, ambivalence and fear comprised a sub-theme. Ambivalence and skepticism concerning general vaccine efficacy was evident in some women’s responses. Vaccine fear was associated with pain from injections and the potential for allergic reactions.
- Sometimes the injection can cause an infection.
- Am afraid of the shot.
- Not everyone’s body system [is] able to take a vaccine [because] they have allergies.
- [You may have a vaccination], but you cannot say you [are] not going to get sick.
Domain 2: Knowledge of HPV
Women’s knowledge of HPV generally was low. Pap smear screening was frequently mentioned as a strategy for disease prevention among the few women who had heard of HPV, although the relationship between HPV and screening was generally not well understood. Many study participants knew that HPV is a sexually transmitted infection that may cause cervical cancer. However, there were some misconceptions about viral transmission and the role of HPV in carcinogenesis. For example, some women felt that sexual transmission of HPV was predicated upon sexual position during intercourse. Others expressed the notion that the virus itself can become cancer. A number of participants confused HPV with HIV and AIDS.
- We heard about cervical cancer, but not HPV.
- I also know you get [HPV] when having sex with several partners or the position that you are taking.
- It’s a virus that could turn into cervical cancer.
- It can lead to AIDS.
Furthermore, the majority of women believed that HPV likely caused discernible physical symptoms (primarily pain, skin irritations and bleeding), and were uncertain about how to reduce their risk of infection. When women were asked where they had learned about HPV, the majority of them indicated audiovisual sources, such as Haitian Kreyol local radio and television programs. To a lesser extent, they had learned from social networks including family, school and church.
Domain 3: Knowledge of HPV Vaccine
Although most women were unfamiliar with a vaccine for HPV, some women likely recognized the vaccine by its branded name, Gardasil®. Among those women, all cited hearing of Gardasil® on television. While some women acknowledged hearing of Gardasil®, its purpose and action remained largely unclear.
- I heard it on TV but never [paid attention to] it. I know it is a vaccine.
- I know [it] is a prevention vaccine, but I have not researched it.
Domain 4: Perceptions of HPV Vaccine
After women were asked to discuss what they knew about the HPV vaccine, the CHW briefly explained the purpose of Gardasil®, so that we could further gauge women’s perceptions of HPV vaccination. While most women felt positively about a vaccine that could prevent HPV infection and cervical cancer, women also felt uncertain about the vaccine since it is relatively new. Participants consistently reiterated the need to seek a doctor’s advice about the vaccine. Others believed the vaccine to be only beneficial for people who had multiple sex partners.
- If it could prevent cancer, it is a good idea.
- It is new, and that is why I’m fearful.
- I’m skeptical because it is new. When [vaccines] first come out [they are] good, but after 3 years they recall them.
- I don’t know if it is good, but my doctor will tell me.
- My first impression is that it’s a good idea for the people that have more than one partner.
Domain 5: HPV Vaccine Intentions
When women were asked if they would consider getting the HPV vaccine for themselves, the majority responded positively, provided the vaccine be affordable and recommended by their doctor. Concerning intent to vaccinate daughters, participants were generally positive, on the conditions that 1) the vaccine was doctor-recommended, and 2) daughters were older and, thus, more likely to be sexually active. Participants overwhelmingly felt that the HPV vaccine would be beneficial for their sons.
- If I really need [the vaccine], I have to be able to pay for it.
- I would have to get my doctor’s point of view first.
- If I’m not active sexually, I will not take it.
- I would have my daughter get the vaccine if she is sexually active.
- At the age of nine, that is too young for my daughter [to be vaccinated].
Conditions of Vaccine Acceptability
When considered collectively, the themes comprising these five domains may serve as indicators of HPV vaccine acceptability among Haitian immigrant women in our study. The themes cluster into broader categories that reflect the conditions under which participants deem the vaccine either acceptable or unacceptable. The most frequently cited reason for vaccination was physician recommendation. Other important factors to warren vaccination were demonstrated vaccine safety, efficacy and affordability. Women also described conditions of HPV vaccination in relation to sexual activity. The vaccine is not suitable for younger, pre-adolescent girls, who presumably are not sexually active and may perceive the vaccine as encouraging the initiation of sexual activity. For monogamous women, getting the vaccine might implicate infidelity and is thus unacceptable. Women felt the vaccine would be most beneficial for persons with multiple sex partners. For the sexually abstinent, women felt the vaccine was not necessary.
For medically underserved women with limited access to routine Pap smears, vaccination against HPV is a promising strategy to reduce suffering and deaths due to cervical cancer. Strategies to educate women about HPV, cervical cancer and prevention of cervical cancer through vaccination must be responsive to women’s knowledge levels of HPV. Among women in our study who had heard of HPV, most were uncertain about the function of Gardasil® to protect against HPV infection. Together, these findings illustrate the need for, and importance of, culturally tailored education to address gaps in knowledge of HPV and cervical cancer. Such basic information must serve as the foundation for effective outreach efforts to promote HPV vaccination and disease prevention.
For the women in our study, multiple factors contribute to HPV vaccine acceptability and such acceptance is predicated upon specific conditions, as illustrated in Table 3. These conditions highlight multiple challenges to implementing vaccination for primary prevention in Little Haiti. For example, physician recommendation was the most frequently cited reason in support of HPV vaccination; however, women also mentioned multiple barriers to accessing the formal healthcare system. Beyond issues of accessibility, women expressed concerns about the safety and efficacy of the HPV vaccine. At the time of this writing, the vaccine is relatively new and remains in post-marketing surveillance in the U.S. Thus, long-term data on the vaccine’s safety and efficacy, which women considered integral to their decision-making, are not yet available. Women also stressed the need for the vaccine to be affordable. Currently, Gardasil® is not uniformly covered by insurers39, resulting in higher out-of-pocket costs. It would almost certainly be cost-prohibitive for women with no health insurance, who have no usual source of care, and who are low-income, which are characteristics disproportionately shared by women in Little Haiti. Utilization of the Vaccines for Children program (for Medicaid-eligible women and young females aged 18 or under), or Gardasil® manufacturer Merck’s Patient Assistance Program, may constitute alternative options to accessing the vaccine. In this instance, Federally-qualified Community Health Centers (CHCs) and other community-based health clinics could serve as key points of distribution for women meeting such age and income eligibility criteria.
Table 3: Conditions of HPV vaccine acceptability
We also uncovered some potential challenges to widespread HPV vaccine adoption related to women’s cultural belief systems and health knowledge. For example, many women felt that the vaccine would be more beneficial to women who have more than one sex partner and not necessary for women in a monogamous relationship. Such reasoning indicates the belief that monogamy confers protection against HPV infection, although some women openly recognized that partner infidelity could increase a woman’s risk of contracting HPV. These assumptions suggest that health education about cervical cancer and HPV should include the topics of past sexual history and multiple partners in discussions of health risk. Further, when considering the HPV vaccine for their sons and daughters, important differences emerged among mothers according to gender. Some mothers were uncomfortable with the vaccine series beginning in pre-adolescence for their daughters, when they believed that their daughters would not be sexually active. This reasoning is important for health professionals to understand, as it demands culturally sensitive education to explain the improved efficacy of Gardasil® if administered prior to the onset of sexual activity. In contrast, the majority of women felt strongly that Gardasil® could be of substantial benefit to their sons when it becomes available and that the vaccine could afford some protection. As participants explained, it is more commonly accepted for boys to have an earlier sexual debut and continue sexual activity with multiple partners through adulthood.
Our study findings are similar to those of other recent studies that assessed HPV knowledge and vaccine acceptability. Tiro and colleagues (2007) analyzed national data from the 2005 U.S. Health Information National Trends Survey (n=3,076) and found that awareness of HPV in the U.S. was generally low. Women who had heard of HPV (approximately 40% of those surveyed) were characterized as younger in age, non-Hispanic whites, with higher education, and having unfettered access to trusted health information and preventive care such as routine Pap screening. As was similar in our study, having some level of familiarity with HPV was not indicative of an accurate understanding of HPV and its role in cervical carcinogenesis40. The women in our study are disproportionately medically underserved; thus, the fact that many women had not heard of HPV, or otherwise incompletely understood HPV, is consistent with national trends. This underscores the need for culturally and linguistically tailored health information.
Concerning vaccine acceptability, Wong and colleagues (2008) held focus groups with ethnically diverse young women (Indian, Malay and Chinese) to discern opinions and perceptions of HPV and found that low knowledge about HPV did not affect women’s acceptance of the vaccine32. Many women felt positively about the vaccine, although they had some concerns about the vaccine’s cost, its relative newness and associated safety, which were similar to the concerns of women in our study. Other findings differed from our study findings, and included women’s concerns about the vaccine being halal, or developed in accordance with Muslim dietary restrictions, as well as its potential to promote promiscuity. Wong and colleagues (2009) also examined HPV vaccine acceptability among mothers of eligible vaccine recipients in the same ethnic Malaysian populations using focus group methodology41. Their findings were similar to those of their previous study among women who were eligible for the vaccine, including an overall positive attitude toward the vaccine, safety and efficacy concerns especially for younger girls, and the monetary cost of the vaccine, which also reflect concerns of the women in our study.
In the U.S., Scarinci and colleagues (2007) assessed HPV vaccine acceptability among Latina immigrants and African American women using focus group methodology31. The majority of participants had never heard of HPV and each focus group was provided with a brief presentation about HPV and cervical cancer. While both ethnic groups felt the HPV vaccine was acceptable, motivations for getting the vaccine, and concerns about the vaccine differed by ethnicity. For example, African American women were more likely to express concerns about safety and efficacy, as well as, about the potential for promiscuous behavior resulting from the use of the vaccine. Latinas had fewer concerns and unanimously indicated they would be willing to get the vaccine. Motivations for immunization among African Americans included affordability, information about the vaccine’s trials results, and having a social network with others who were immunized. Latinas felt that widespread adoption of the HPV vaccine would need to be preceded by a large-scale educational effort that involved multiple points of information dissemination including Spanish language media, doctors’ offices, churches and peers. Our participants also indicated the importance of utilizing multiple sources, including churches, physician offices and Kreyol-language media, to promote HPV vaccine education.
Our findings, in conjunction with those of other researchers, point to the need for intervention development that is community-based, as well as responsive to cultural beliefs and literacy levels, to achieve widespread acceptance of the HPV vaccine. In the U.S., there is a serious lack of educational information available in Haitian Kreyol about HPV and cervical cancer. Women in our study requested more education and strongly suggested the use of trusted resources through which to deliver such information (e.g., Haitian physicians, Haitian Community Health Workers, and especially, using audiovisual media in consideration of low literacy and limited English proficiency).
The affiliation between the CHWs and this organization was, in many ways, critical to the study’s success. By providing the study a 'community home,' we did not encounter many barriers to implementation and, perhaps more importantly, were able to build organizational capacity to support future research and intervention.
There are some limitations to this study. As a qualitative, exploratory study, our findings are not clearly generalizable to all Haitian immigrant women. Additionally, the CHW who conducted the focus groups was the only person to transcribe the focus group recordings in Kreyol and provide interpretations of responses in English. In spite of this limitation, the CHW’s long-term experience in working on community health issues in Little Haiti, familiarity with the community, and full proficiency in both Kreyol and English lend her invaluable insight into participants’ responses and discussion. Such insight and language proficiency allows for better accuracy for interpreting meaning from focus group dialogue.
Our findings represent a first attempt to understand HPV vaccine perceptions among Haitian women in the U.S., who experience an excess burden of cervical cancer. Our findings can guide further formative research to develop a culturally relevant, community-based educational intervention about HPV vaccination. This work also adds to the growing body of literature on vaccine uptake in cross-cultural populations.
The authors would like to thank the members of the Patnč en Aksyon’s Advisory Board for their commitment to improving the health of Haitian women in Little Haiti, as well as our Community Health Worker (CHW), Lyssa Larsen, who collected study data and helped to garner community support for future research and intervention in Little Haiti. This research was funded by the National Cancer Institute (R21-CA-11981-01), the American Cancer Society (MRSGT-07-159-01-CPHPS) and the University of Miami Sylvester Comprehensive Cancer Center.
1. Racial and Ethnic Disparities in Cancer Screening: The Importance of Foreign Birth as a Barrier to Care. Journal of General Internal Medicine. 2003; 18:1028-35.
2. de Alba I, Hubbell FA, McMullin JM, Weningson JM, Saitz R. Impact of U.S. citizenship status on cancer screening among immigrant women. Journal of General Internal Medicine. 2005; 20(3):290-296.
3. Hiatt R, Pasick R, Stewart S, Bloom J, Davis P, Gardiner P, et al. Community-based cancer screening for underserved women: design and baseline findings from the Breast and Cervical Cancer Intervention Study. Preventive Medicine. 2001; 33(3):190-203.
4. Freeman H, Wingrove B. Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities. In: DHHS US, editor.: National Cancer Institute; 2005.
5. FCDS. Florida Cancer Data System. 2007.
6. CDC CfDCP. Cervical Cancer: Compare by State. Atlanta, GA: Centers for Disease Control & Prevention, U.S. Cancer Statistics Working Group; 2004 [cited 2008 November 17]; Available from: http://www.cdc.gov/cancer/cervical/statistics/state.htm.
7. Green EH, Freund KM, Posner MM, David MM. Pap Smear Rates Among Haitian Immigrant Women in Eastern Massachussetts. Public Health Reports. 2005; 120:133-139.
8. Fruchter RG, Remy JC, Burnett WS, Boyce JG. Cervical cancer in immigrant Caribbean women. American Journal of Public Health. 1986; 76(7):797-799.
9. Adler N, Ostrove J. Socioeconomic status and health: what we know and what we don't. Annals of the New York Academy of Sciences. 1999; 896:3-15.
10. Irwin A, Valentine N, Brown C, Loewenson R, Solar O, al. e. The Commission on Social Determinants of Health: Tackling the Social Roots of Health Inequities. PLoS Medicine. 2006; 23;3(6):e106 doi:10.1371/journal.pmed.0030106.
11. Saint-Jean G, Crandall LA. Sources and Barriers to Health Care Coverage for Haitian Immigrants in Miami-Dade County, Florida. Journal of Health Care for the Poor and Underserved. 2005; 16:29-41.
12. CDC CfDCP. National Center for Chronic Disease Prevention and Health Promotion: Behavioral Risk Factor Surveillance System. Atlanta, GA2008 [cited 2008]; Available from: http://www.cdc.gov/brfss/.
13. Kobetz E, Menard J, Barton B, Pierre L, Diem J, Denize Auguste P. Patne en Akyson: Addressing Cancer Disparities in Little Haiti through Research and Social Action. American Journal of Public Health. 2009; 99(7):1163-1165.
14. National Cancer Institute Factsheet: Human Papillomaviruses and Cancer. Available from: http://www.cancer.gov/cancertopics/factsheet/Risk/HPV.
15. Centers for Disease Control and Prevention. Condoms and STDs: Fact Sheet for Public Health Personnel. Available from: http://www.cdc.gov/condomeffectiveness/latex.htm.
16. Markowitz L, Dunne E, Saraiya M, Lawson H, Chesson H, Unger E.. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMWR) March 12, 2007 / 56(Early Release); 1-24.
17. Trottier H, Mahmud SM, Lindsay L, Jenkins D, Quint W, Wieting SL, Schuind A, Franco EL; GSK HPV-001 Vaccine Study Group. Persistence of an incident human papillomavirus infection and timing of cervical lesions in previously unexposed young women. Cancer Epidemiology, Biomarkers & Prevention. 2009; 18(3):854-862.
18.&nHarper DM. Current prophylactic HPV vaccines and gynecologic premalignancies. Current Opinion in Obstetrics and Gynecology. 2009; 21(6):457-464.
19. Bonanni P, Boccalini S, Bechini A. Efficacy, duration of immunity and cross protection after HPV vaccination: a review of the evidence. Vaccine. 2009; 29;27 Suppl 1:A46-53.
20. Constantine NA, Jerman P. Acceptance of human papillomavirus vaccination among Californian parents of daughters: a representative statewide analysis. Journal of Adolescent Health. 2007; 40(2):108-115.
21. Dempsey AF, Abraham LM, Dalton V, Ruffin M. Ann. Understanding the reasons why mothers do or do not have their adolescent daughters vaccinated against human papillomavirus. Epidemioly. 2009; 19(8):531-538.
22. Stupiansky NW, Rosenthal SL, Wiehe SE, Zimet GD. Human papillomavirus vaccine acceptability among a national sample of adult women in the USA. Sex Health. 2010; 7(3):304-309.
23. Zimet GD, Weiss TW, Rosenthal SL, Good MB, Vichnin MD. Reasons for non-vaccination against HPV and future vaccination intentions among 19-26 year-old women. BMC Women’s Health. 2010; 1;10:27.
24. Bednarczyk Birkhead GS, Morse DL, Doleyres H, McNutt LA. Human papillomavirus vaccine uptake and barriers: Association with perceived risk, actual risk and race/ethnicity among female students at a New York State university, 2010. Vaccine. 2011 Mar 4. [Epub ahead of print]
25. Cui Y, Baldwin SB, Wiley DJ, Fielding JE. Human papillomavirus vaccine among adult women: disparities in awareness and acceptance. American Journal of Preventive Medicine. 2010; 39(6):559-563.
26. Kobetz E, Kornfeld J, Vanderpool RC, Finney Rutten LJ, Parekh N, O'Bryan G, Menard J.Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention. Journal of Health Communication. 2010; 15:22-29.
27. Minkler M, Wallerstein N. Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2003.
28. Israel B, Schulz A, Parker E, Becker A, Allen A, Guzman R. Critical Issues in Developing and Following Community Based Research Principles. San Franciso, CA:Jossey-Bass; 2003.
29. Edgren K, Parker E, Israel B, Lewis T, Salinas M, Robins T, et al. Community involvement in the conduct of a health education intervention and research project: Community Action Against Asthma. Health Promotion Practice. 2005; 6:263-269.
30. Gerend MA, Lee SC, Shepherd JE. Predictors of human papillomavirus vaccination acceptability among underserved women. Sexually Transmitted Diseases. 2007; 34(7):468-471.
31. Scarinci IC, Garces-Palacio IC, Partridge EE. An examination of acceptability of HPV vaccination among African American women and Latina immigrants. Journal of Women's Health (Larchmt). 2007;16(8):1224-1233.
32. Wong LP. Young multiethnic women's attitudes toward the HPV vaccine and HPV vaccination. International Journal of Gynecology & Obstetrics. 2008; 103(2):131-135.
33. Zimet GD, Liddon N, Rosenthal SL, Lazcano-Ponce E, Allen B. Chapter 24: Psychosocial aspects of vaccine acceptability. Vaccine. 2006; 24 Suppl 3:S3/201-209.
34. Cates JR, Brewer NT, Fazekas KI, Mitchell CE, Smith JS. Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women. The Journal of Rural Health. 2009; 25(1):93-97.
35. Krippendorff K. Content analysis: an introduction to its methodology By 2nd ed. Thousand Oaks, CA: Sage; 2004.
36. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, CA: Sage; 2002.
37. Creswell JW. Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage; 1998.
38. Corbin J, Strauss AL. Basics of qualitative research: Grounded theory procedures and techniques. 3rd ed. London: Sage; 2007.
39. Keating K, Brewer N, Gottlieb S, Liddon N, Ludema C, Smith J. Potential barriers to HPV vaccine provision among medical practices in an area with high rates of cervical cancer. Journal of Adolescent Health 2008; 43(4 Suppl):S61-67.
40. Tiro J. What do women in the U.S. know about human papillomavirus and cervical cancer? Cancer Epidemiology Biomarkers & Prevention. 2007; 16(2):288-294.
41. Wong LP. Preventing cervical cancer through human papillomavirus vaccination: perspective from focus groups. Journal of Lower Genital Tract Disease. 2009; 13(2):85-93.