Development of a theory-based HPV vaccine promotion comic book for East African adolescents in the US

A half-page storyline for the comic book was created by the research team. The story considered previous literature on vaccine barriers and facilitators [4, 28] and was informed by two behavioral theories: Health Belief Model (HBM) [29] and Theory of Reasoned Action (TRA) [30]. Bilingual research team members translated the storyline from English into Somali, Amharic, and Tigrinya. Table 1 presents the storyline for each scene, which was superimposed onto photos of adolescents that resembled members of the target communities. Images were obtained from health promotion materials and inventories of publicly available stock photos. The comic book mock-up was reviewed for cultural relevance by East African community members and our bilingual/bicultural research team.

The focus group moderator guide included questions on socio-cultural beliefs around HPV vaccines and specific questions about the comic book mock-up on storyline content, featured characters, overall graphic design, and cultural relevance of the comic book mock-up. Examples of questions about the mock-up included ‘How clear was the information presented in the material?’, ‘What are your thoughts about the characters, the story, and the setting?’, ‘Should other family members be included as characters?’, ‘If so, who should be included?’, and ‘How do we make this material more culturally appropriate to your community and to the adolescents?’ Focus group sessions were conducted in Somali, Amharic, or Tigrinya, audio recorded and translated from Somali, Amharic, or Tigrinya into English.

Data analysis involved three steps. First, researchers met after each focus group, developed notes on key themes, and provided feedback to the moderator for the next focus group to clarify emerging themes. Second, two researchers independently reviewed each transcript and used inductive, constant comparison approach to identify concepts. Using an iterative process, the researchers met biweekly to refine the codebook, adding, removing, and revising codes as needed to address inter-rater agreement and to compare new codes with existing codes. Third, we reached consensus around themes identified throughout the coding and analysis process. The data were organized using ATLAS.ti, version 7.

From October 2017 to September 2018, mothers and their adolescent children were recruited to participate in ethnolinguistic-centric educational dinners on HPV vaccination. Dinners included both an interactive educational forum intervention for mothers (to promote HPV vaccination in their 11–17-year-old children) and the comic book intervention for 14–17-year-old adolescent children. Dinners were held in Somali or Amharic only; no dinners were held in Tigrinyan due to insufficient staffing to support recruitment and data collection, and therefore we did not evaluate acceptability of the Eritrean comic book version. Mothers were eligible to participate if they spoke Somali or Amharic fluently or very well, had ≥1 child aged 11–17 years, and reported that all of their children were either unvaccinated against HPV or that they did not know if their children had been vaccinated. Mothers were invited to bring ≥1 child aged 14–17 years to participate in the comic book intervention if the child was able to speak and read English fluently or very well. Bilingual staff members recruited mothers face-to-face at community events. Our community partners also provided contact information for potential participants for telephone recruitment. The staff member explained the study in the woman’s native language and collected children’s age, gender, and HPV vaccination status. Additional demographic and immigration information were collected for participating women. Mothers provided written informed consent in their native language on behalf of themselves and their participating children. Children provided verbal assent. At the events, mothers and adolescents ate dinner together before participating in separate educational activities on HPV vaccines. Mothers participated in an interactive native language presentation led by a bilingual co-ethnic health care provider, while adolescents read the comic book. Adolescents and their mothers each received $25 for participating.

Each participating child was given a copy of the comic book and asked to respond to four open-ended questions (Additional file 1) after reading the comic book: 1) adolescents’ thoughts about the comic book in general, 2) what adolescents liked and did not like about the comic book, 3) their thoughts on whether other adolescents would like the comic book and why, and 4) what messages in the comic book were important to them.

The research team conducted content analysis, and excerpts were counted of the acceptability data. For the content analysis, two research team members independently reviewed each transcript to identify major categories and codes and created a tentative coding scheme. The researchers refined the coding scheme throughout data analysis. Discrepancies were resolved via reconciliation. Once the content analysis was completed, the research team counted the number of excerpts identified under the major categories and codes to calculate the frequency and the proportion of the excerpts.

Mothers across the focus groups reported that the comic book should include diverse characters, including girls and boys from different races and ethnicities, feature the main character to be from the community, and show families. Mothers indicated that the main characters should look like they are “from the community.” Somali mothers had specific input on how the main character should look, saying girls should be “wearing hijab and dressed modestly.” There was a consensus across the focus groups about the importance of showing families. However, conversations diverged when discussing which family members to highlight. Somali mothers suggested grandmothers and fathers; however, Ethiopian mothers stated that the inclusion of mothers was sufficient, as shown in the mock-up. Discussing the storyline, an Ethiopian mother emphasized the central role mothers play in the family.

Here … is Senait [the main character], Helen [character’s friend], doctor, mother, and students. Mother means and represents the whole family, the doctor is here to tell what the vaccine is … Senait is there to tell the information to her mother, what she heard from her friend...So, I don’t think it is important to include additional people in the story.

Mothers across the focus groups also mentioned about the importance of including both boys and girls together in the story and responded positively to the exchange of information between boys and girls illustrated in the mock-up as being realistic. An Ethiopian mother said:

[pointing to the group picture], this is effective in showing that boys share information to girls and the girls share information to boys, and prevent themselves from the disease.

Mothers expressed that they had a lack of information about HPV infection transmission, treatment, and prevention. Some mothers mentioned the importance of understanding the “risks and benefits” of the HPV vaccine in making vaccine decisions and stated that the mock-up captured these well. A Somali mother shared this sentiment by commenting on the storyline:

I think the message here is that when you explain something to someone, they’ll understand it. The person [referring to the main character] was unsure before and thought it was a bad thing, and then … when the benefits of the shot and the dangers of the disease were explained … understood and was able to act on it and get the vaccine.

The mothers responded positively to the deep connection between “the girl and her mother” and their affective interaction in the storyline. Ethiopian mothers also identified with the humorous twist about the pain message, with mothers bursting out laughing when the focus group moderator read that section of the script (where the main character’s friend tells the main character that getting vaccinated is an easier pain compared to studying for their next math test). Mothers emphasized that “most of the time children talk about the pain” for vaccination and responded positively that the comic book addressed pain. An Ethiopian mother described how she anticipates her child’s response to the message.

I am very happy and excited to see this [the story]. For me the story is very good, particularly talking about the pain. My child understands a message better when communicated this way than [when] I tell him.

Across all focus groups, mothers discussed the influence that peers have on their children. Mothers stated that their children “listen,” “feel comfortable,” and “learn better” from their peers rather than from parents. They also mentioned that their children had more access to information as they are more assimilated to western culture. An Eritrean mother explained that these differences in acculturation can create parent-child communication challenges and discussed the importance of having peers educate one another.

Our children think we don’t know and don’t understand, and that is why they don’t listen to our advice. They don’t understand us. I really think that having young people close to their age talking to them would work best.

Mothers agreed that if their children get information from multiple sources, it helps validate what they have heard and enhances message persuasion. Across all focus groups, mothers thought children were exposed to information from school, peers, healthcare providers, and community centers; they recommended that this was portrayed in the comic book.