Background
The humanpapilloma virus (HPV) is sexually transmitted and has been conclusively linked to cervical cancer (CC) and genital warts [
1,
2]. Multi-parity, early sexual debut and infection with other sexually transmitted infections (STIs) are known to be risk factors for HPV and CC [
3]. HPV infection is so common that it’s suggested that 20 % of sexually active adolescent girls will be infected by the age of 18 [
4]. As 70 % of infections clear within a year however, only a small proportion of women who develop persistent infection from high risk genotypes go on to develop cancer [
5]. CC is attributed to approximately 1100 deaths annually in the United Kingdom (UK) [
6]. CC ranks second in the most common female cancers globally [
7], and is the main cause of female cancer mortality worldwide [
8], especially in Sub-Saharan Africa [
9].
Since 1979, CC mortality rates in the UK have reduced by nearly 70 % due to the introduction of the cervical screening programme in 1988; and more recently the HPV vaccination programme [
10]. The HPV vaccine has been proven to reduce the risk of CC [
11]. Nearly all the girls vaccinated against the HPV virus will be protected against three-quarters (75 %) of CC incidences [
10]. To increase efficacy, the vaccine must be given before sexual debut [
12]. It has been suggested that adolescents are becoming sexually active earlier [
5], therefore, in the UK, the HPV vaccine has been offered to 12-13year old girls since September 2008 through schools, as part of their childhood immunization programme [
13]. HPV vaccination programmes together with cervical screening are expected to reduce CC incidence rates and mortality rates [
14], thereby reducing disease burden on the victims of CC and their families [
15]. It is noted that programme success is influenced by awareness and that lack of awareness impacts negatively on uptake [
16]. Raising awareness in parents is central to influencing HPV vaccine uptake as they are the decision makers [
17]. Lack of parental awareness can result in vaccine decline, and school nurses, who are the primary deliverers of the vaccine, have expressed reluctance to vaccinate adolescent girls without parental consent [
5]. Consequently, parents of adolescent girls need to be aware of HPV, and how it is transmitted and the efficacy of the HPV vaccine in preventing CC [
17].
Generally, awareness in the UK has increased since the introduction of the school based vaccination programme which was preceded by various health campaigns [
18]. A study by Marlow et al. [
19], reported a positive correlation between having a daughter aged between 9 and 17 years and increased awareness in UK parents. Women are reported as having higher levels of awareness of both HPV and the vaccine than men [
19], however, black women are reported to have lower levels of HPV awareness compared to their white counterparts, and less likely to have heard about the HPV vaccine [
18]. Previous studies have indicated that black women from Sub-Saharan Africa have a limited knowledge pertaining to HPV and CC [
9,
17]. It is argued that limited awareness will invariably affect vaccine acceptability and therefore vaccine uptake [
18] and that poorer knowledge pertaining to CC, and its link with sexual activity and HPV is associated with vaccine refusal [
13].
Although there is a generally good uptake of the vaccine, a feasibility study conducted prior to the nationwide initiation of the programme, indicated significantly lower vaccine uptake in schools where students from ethnic minority groups were proportionately higher [
20]. More specifically, Hawker et al. [
21] suggested that black parents have poorer uptake of childhood immunizations, falling behind their Asian and white counterparts. This is a cause for concern. It is argued that CC is a disease of disparities, with factors such as race, ethnicity, socio-demographic and socioeconomic factors playing an important epidemiological role [
16] with suggestions made that women from ethnic minority groups are particularly vulnerable to CC [
3,
15].
Such findings suggest that research into the attitudes of minority groups towards the HPV vaccine is necessary. Gordon et al. [
13] carried out research with the Jewish population in the UK, but no UK studies appear to have been carried out with the African population. Most research in this field has been based in America. Internationally, several studies have been conducted exploring the attitudes of mothers towards HPV vaccination, but fathers have generally been neglected. A study by Marlow et al. [
1] found that mothers who thought their partners would be favourable to vaccination were likely to accept vaccination for their daughters. The male presence within the family unit is typically one of authority, thus a father holds the greater power in the decision-making process in all matters including sexuality, reproduction and matters pertaining to the children [
22]. This is of particular importance in the African context, where the man in any relationship is the decision maker [
22], making it impossible for mothers to act without permission from their husbands [
23]. Generally, African women hold a lower social status and are disempowered, and the African tradition favours this [
23]. This brings to the fore the importance of fathers in the decision making process in relation to HPV vaccination.
In addition to issues of gendered power Wamai et al. [
17] suggest that other social and cultural factors influence HPV, HPV vaccine and CC awareness. Attitudes and beliefs similarly influence vaccine acceptability [
24]. There has been a resurgence of religion within many Africans in previous several decades, possibly born from a desire by Africans to search for salvation/escape from their impoverished socioeconomic conditions [
25]. Religious beliefs dictate no sex outside of marriage, and these beliefs can impact on risk perception, and ultimately vaccine acceptability [
13]. Religious values may make it difficult for parents to find acceptable any interventions that seem to be linked to sexual behaviour [
25]. A study by Gordon et al. [
13], found that religious beliefs played a pivotal role in the decision-making process in matters pertaining to sexual behaviour.
In addition, compared to other races, black women are reported as being less receptive of the HPV vaccine [
18], amid concerns about possible side effects and uncertainty of the vaccine’s effectiveness [
26].
For the reasons outlined, the present study sought to explore attitudes towards HPV vaccination among UK based African parents of daughters aged between 8 years and 14 years.
The study had three objectives:
Methods
Participants were recruited and interviewed by ETM. The study adopted a descriptive qualitative design. Face to face semi-structured interviews were conducted allowing for the collection of rich, in-depth data [
28]. Purposive snowball sampling was used to select the participants who were recruited via gatekeepers from an African social club in a city in the north of England. Given the focus of the study, participants had to be African parents with at least one daughter aged 8–14 years. Single parents where the other parent was not contactable for research purposes were excluded as it would not have been possible to address the third objective of the study. Divorced, separated, and families where one parent was not willing or unable to participate in the study were also excluded for the same reason, and were not recruited. Willing participants were provided information sheets outlining the study; that participation was voluntary, that their anonymity would be maintained (pseudonyms were used); when and how they could withdraw from the study; that interviews would be tape-recorded and how and when they would be destroyed, and were given 5 days to consider whether or not they wished to participate. No incentives were offered for participation.
Interviews were conducted in study rooms located within the university library. The interview duration was approximately one hour long. The interview schedule was based on the study objectives, and covered topics such as how long they have lived in the UK, number of daughters, their understanding of cervical cancer, their understanding of HPV and the vaccine, what they think is the appropriate age for vaccination, and their spouse’s perceptions about vaccination, and their ability to discuss vaccination with their spouse. Discussion topics also included who makes decisions within the family, and if they have any daughters already vaccinated, and reasons for any previous vaccine refusal. Each participant was interviewed without their partner. After a total number of 5 mothers and 5 fathers were recruited and interviewed, a point of data saturation was reached, i.e. no new information was forthcoming [
29]. All interviews were recorded, transcribed, and analysed using thematic data analysis by hand. An inductive approach to the analysis was used. To enhance validity, participants were provided copies of their transcripts to check for accuracy [
28]. The sample size was small, and was a limitation of the study.
The male participants were unwilling to provide their exact ages, something which could be resultant from the fact that the interviewer was an African woman. Given the reluctance of the male participants to provide their exact ages on account of the interviewer’s gender, it cannot be entirely ruled out that they may have responded differently to being interviewed by a man. It is unlikely however that their perceptions would have been different had the interviewer been male. The study did not note other demographic factors. It is acknowledged that literature suggests factors such as socio-economic status and educational levels may influence health behaviour [
16]. However, in the present study, there were no obvious differences between the attitudes of the participants according to incidental demographic variances which emerged during the data analysis. For example, the attitudes of the nurse from Kenya, despite having a higher level of educational attainment, were in accord with the rest of the cohort.
Conclusion
The results of the study indicate that the HPV vaccine is generally unacceptable within the African population, with culture and religion influencing risk perceptions and playing important roles in vaccination decision making. Mistrust for the vaccine was also evident, and a general mistrust for the west from which the vaccine originates. HPV and CC knowledge was low, and there was a misconception pertaining to the causes of CC; all which contributed to vaccine decline. To increase uptake, parents should be provided tailored HPV information that addresses religious and cultural issues specific to the African population [
42]. This is important because HPV information from the schools was generally misinterpreted, as some parents continued to believe that it should be administered to girls of questionable moral behaviour only, implying that it works to prevent HPV in those who are already sexually active, contrary to literature. It would appear that the information received from the schools was not understood in its entirety. Africans are people with deep cultural roots, which influence their health behaviour [
27], and this together with their religious values should be reflected in health messages. Health information should stress the fact that the vaccine is most effective when given to girls who are not yet sexually active, and importantly that girls can be at risk because of exposure to the virus, not through their own sexual behaviour, but their partners, namely husbands. Mentioning husbands could influence vaccine acceptability, as this does not imply promiscuity on the girls’ part. The interview did not change the perceptions of any of the participants towards HPV vaccination.
Audience segmentation and targeting health communication to smaller more homogenous subgroups can make it easier to determine the factors shared by members of a selected subgroup with increased disease burden, and thus tailor information to suit [
49]. Health information with short story lines focusing on religion and HPV vaccination may also improve HPV health literacy, where the target group are able to identify with the characters portrayed in the short skit; identifying with the source of the message, or persons portrayed in the message has been proven to enhance effective communication, and consequently service uptake [
49]. Involving key influential people e.g. church leaders from within the targeted community in health campaigns may influence vaccination uptake [
34]. Community representatives should be involved in designing a message that serves the needs of the study population [
7]. The use of celebrities in health messages may also be beneficial, especially male celebrities, as this might influence vaccine acceptability for fathers, who in the African context are the ultimate decision makers. Furthermore, considering the importance of African fathers in HPV vaccination decision making, they should not be excluded from any future research in this population. As with other qualitative research, the results of this study cannot be generalised and is a limitation of the study.