From Going out Half-Done to Fully Protected: Intrinsic and External Motivators in HPV Vaccine Decision-Making Across Cultures

Abstract

Background: The introduction of the human papilloma virus (HPV) vaccine has allowed for incredible strides in the reduction in HPV-related cancers. Despite widespread availability and a recent age group expansion for the vaccine, uptake remains low. Particularly, concerning disparities exist in the state of Tennessee and among minority women. This study aimed to identify key influences of decision-making to receive the HPV vaccine in minority women living in Tennessee. Methods: This study used a prospective, observational, qualitative methods approach. Minority women residing in Tennessee were recruited through flyers posted in various community-based locations around the state. Narrative interviews of participants were conducted until thematic saturation was achieved. Interviewing occurred telephonically, with questions focused on participant perceptions of HPV and its vaccine. Verbatim transcripts were created via external software, and then inductively coded by three researchers. These codes were grouped into categories based on similarities, which facilitated the emergence of themes. Results: A total of 21 participants were interviewed between July and October 2024. Thematic analysis revealed two themes: (1) Awareness of HPV: Determining if the Vaccine is Right for Me; and (2) Intrinsic Motivators for HPV Vaccine adoption: “Like going to the salon and getting your hair half-done”. While some participants had an accurate understanding of HPV, its health consequences, and had received the vaccine, most were unvaccinated and had little understanding of the benefits of this preventative method. Those who received the HPV vaccination were influenced by proactive healthcare workers who provided in-depth education about its benefits. Those who did not elect to receive the vaccine described how its lack of mandate and seldom informational opportunities impacted their decision. Conclusions: Overall, minority women in Tennessee could benefit from improved access to information regarding HPV and its vaccine, as well as direct provider influence and counseling on receiving the vaccine to avoid detrimental health consequences.

1. Introduction

Human papilloma virus (HPV) remains the most predominant sexually transmitted infection in the United States (US). HPV infection can result in several types of cancer, primarily cervical. The mortality rate for cervical cancer from 2000 to 2012 was 5.0 deaths per 100,000 women and was significantly greater among Black women at 10.1 per 100,000 [1]. Fortunately, advancements in medical technology for preventative cancer screening, including the Pap and HPV tests, as well as the introduction of the HPV vaccine, in conjunction with comprehensive public health campaigns, have substantially decreased both the incidence and mortality rates associated with cervical cancer [2]. Since the introduction of the HPV vaccine in the United States in 2006, the Centers for Disease Control and Prevention (CDC) report an 81% decrease in the prevalence of HPV infections linked to HPV-related cancers among young adult women and a 40% decrease in the incidence of the HPV types that are most often connected to cervical cancer [3].

Despite the availability of safe and effective HPV vaccines, and a recent expansion in the qualifying age range up to 45 years, vaccination rates remain suboptimal. A cross-sectional study observed that only 25.8% of young adults of both sexes aged 18–26 years old had received at least one dose of the HPV vaccine [4]. The HPV vaccination rate was lower in women of color, with 24.7% and 21.9% of Black and Hispanic women, respectively, receiving at least one dose compared to 28.9% of White women [4]. A retrospective analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) indicated that young adult women aged 18–26 in the southern United States had the lowest rates in the US for starting and completing the HPV vaccination series [5]. Specifically, 30.4% of southern-residing women received their first dose, while only 17.7% completed the three-dose series [5]. Even fewer young women were vaccinated in Tennessee where the 2023 average HPV vaccination rate was 28.6% among young adults aged 18–26 years old [6]. Data from Boakye et al. (2021) reinforce this trend, reporting that the South had significantly lower HPV vaccine initiation (33.4%) and completion (14.5%) rates in adults aged 18–26 compared to the Northeast, who had the highest rates of initiation (55.9%) and completion (30.9%) [7]. Within the South, there was considerable variation among individual states. For example, McLendon et al. (2021) reported that in Alabama, a state with one of the highest cervical cancer mortality rates in the country, only 47% of surveyed college students had initiated the vaccine, and merely 17.4% had completed the three-dose series [8]. Similarly, other southern states such as Kentucky, Mississippi, Tennessee, and South Carolina consistently rank among the lowest for HPV vaccination rates while experiencing some of the highest rates of HPV-associated cancers [8].

Furthermore, a prior systematic literature review identified various obstacles to receiving the HPV vaccine, including cost and safety concerns [9]. It is important to note that women and specifically minority women are more likely to encounter HPV-related disparities, which remains a critical concern that must be addressed [10].

Disparities in cervical cancer incidence and mortality rates by race persist in the US, demonstrating a substantial need to empower all women to receive the HPV vaccination [11]. Previous studies evaluating cancer rates among Asian American women have demonstrated that Vietnamese women have higher cervical cancer rates compared to other Asian American women [12]. Furthermore, research has also reported that HPV-associated diseases negatively impact women from marginalized groups, such as African Americans and Latinas [13,14]. Understanding the factors related to low HPV vaccination rates, especially among women of color in Tennessee, requires a detailed examination of personal historical and social contexts influencing their healthcare experiences. Addressing these disparities may require collaborative efforts involving healthcare providers, policymakers, community leaders, and individuals to ensure equitable access to information and resources to diminish their burden of HPV-related cancers. This qualitative study aimed to identify common perceptions of HPV and its vaccine, as well as factors which influenced decisions to initiate and complete the series.

2. Methods

2.1. Study Design

This study employed a prospective, observational, qualitative methods approach to interviewing minority women residing in Tennessee. Narrative interviews were conducted to gather personal stories, as this method has successful utilization in previous studies to uncover cultural beliefs, motivators, and social constructs related to the HPV vaccine [15,16]. In particular, the success of narrative interviews can be used in audiences that have low awareness or exhibit resistance to traditional approaches. This technique has also previously been applied to specially investigate HPV vaccination decision-making [17]. The interview guide, which was developed from previous studies, was structured to elicit participant perceptions and experiences regarding the HPV vaccine [18,19,20,21]. The interviews were composed of open-ended questions, each designed to deeply probe the participant’s views on the HPV vaccine. They commenced with a broad question, “When you hear someone say, ‘human papillomavirus (HPV) vaccine,’ what do you think of instantly?”, to allow the participants to share their opinions. Additional interview questions are presented in

Table 1. Interview questions.

When you hear someone say “human papillomavirus” or “HPV” what do you think of instantly? Who can get it? What diseases does HPV cause/produce? How can it be transmitted?

What about the HPV vaccine, what do you think of instantly?

Let’s say you are about to receive the HPV vaccine—how many shots would you get?

Have you ever received the vaccine? If yes or no: Would you like to share with us the decision-making process? Going back in time to when you were vaccinated, could you recall the feelings you experienced?

What are the reasons you should get the vaccine? What about not getting vaccinated?

What might prevent you from receiving the vaccine?

How would you describe these feelings?

.

2.2. Setting, Participants, and Data Analysis

Upon Institutional Review Board (IRB) approval at the University of Tennessee Health Science Center, eligible participants were recruited through flyers placed in libraries, gyms, recreational centers, restaurants, community centers, and open markets across the state. The snowball technique was also utilized to recruit respondents who were English-speaking Latinx and Asian women according to qualitative guidelines outlined by Morse [22,23]. Inclusion criteria consisted of minority females between the ages of 18 to 45 and residing in Tennessee. Additionally, participants were required to provide a reliable phone number and email address, as well as be open to sharing their perspectives on the HPV vaccine.

Telephone interviews were conducted from July to October 2024 and completed when data saturation occurred [24]. Two experienced researchers, trained in qualitative data collection, facilitated the interviews. An original, semi-structured interview guide was utilized in all interviews to ensure consistency and reliability of data collection [17]. The interview began with demographic questions and proceeded to general questions of awareness about HPV and the HPV vaccine, as shown in Table 1. The interview proceeded with discussion surrounding the factors motivating women of color to receive the HPV vaccine. All the telephone interviews were recorded using a digital audio recording device and were transcribed verbatim by an external agency [25].

Transcribed interviews were analyzed using narrative inquiry. Previous qualitative studies querying women about HPV have been shown to effectively identify the factors motivating women to receive the HPV vaccine [16]. After completing all interviews, the transcripts were de-identified, assigned participant numbers, and uploaded to Dedoose^®, a qualitative software (Version 9.0.17, Los Angeles, CA, USA). A primary coder trained with extensive experience in qualitative research methods and analysis conducted inductive line-by-line coding for half of the interviews [16]. A second coder analyzed the remaining interviews. As relationships between the codes and categories emerged, the research team confirmed and refined these codes and relationships through an iterative process [16]. Conceptual categories were identified and grouped into properties linked to these relationships.

Finally, emergent themes were compiled, along with supporting quotes from the interviews [16]. In contrast to quantitative methods, which use statistical formulas to determine sample size, qualitative research relies on concepts such as thematic saturation, which is a pivotal stage in data collection that is reached when no new themes, patterns, or insights emerge from additional narrative interviews [26]. In this study, data saturation represented that a comprehensive understanding of the participants’ awareness of the HPV vaccine and the disease was attained. The narrative interviews were then reviewed by two researchers (AC and KC), who confirmed that thematic saturation was reached for all the questions by interview 20. Although thematic saturation was achieved, the team decided to conduct an additional interview because it was already scheduled. Finally, the themes were reviewed by a third independent researcher to prevent researcher bias and ensure rigor, as evidenced by Lincoln and Guba’s Evaluative Criteria [27]. The team then met multiple times to discuss the codes and created a unified code frame [27]. Transferability was achieved by providing detailed descriptions that align with the context. Each theme was supported by “rich” quotations from the participants’ transcripts [27]. Furthermore, most quotations are presented with interpretations that closely reflect the participants’ intended meanings, which further engage the reader in the interpretive process by encouraging them to reflect thoughtfully [27]. Additionally, credibility was maintained throughout all stages of data collection and analysis [27]. Figure 1 presents a synthesis of all methodology procedures.

3. Results

A total of 43 participants initially expressed interest in the study and provided their information. After screening for inclusion criteria and verifying reliable phone numbers, only 23 participants met the eligibility requirements. Additionally, two participants withdrew from the study due to scheduling conflicts. A total of 21 participants were interviewed.

Table 2. Demographic characteristics of study participants.

Participant	Ethnicity	Age	County	HPV Vaccination Status
P1	African American	32	Davidson	Non-Vaccinated
P2	African American	41	Davidson	Non-Vaccinated
P3	African American	31	Shelby	Partially Vaccinated
P4	Latina	23	Rutherford	Partially Vaccinated
P5	African American	29	Davidson	Partially Vaccinated
P6	Latina	40	Rutherford	Non-Vaccinated
P7	African American	24	Davidson	Non-Vaccinated
P8	African American	26	Davidson	Partially Vaccinated
P9	Latina	18	Rutherford	Unsure
P10	Latina	31	Rutherford	Non-Vaccinated
P11	Latina	19	Montgomery	Fully Vaccinated
P12	African American	27	Shelby	Non-Vaccinated
P13	African American	32	Shelby	Partially Vaccinated
P14	Chinese	22	Knox	Non-Vaccinated
P15	African American	39	Davidson	Non-Vaccinated
P16	Vietnamese	27	Hamilton	Fully Vaccinated
P17	Latina	32	Davidson	Non-Vaccinated
P18	Latina	24	Rutherford	Non-Vaccinated
P19	Indian/South Asian	39	Davidson	Fully Vaccinated
P20	African American	23	Davidson	Non-Vaccinated
P21	African American	25	Davis	Fully Vaccinated

presents the demographic characteristics of the participants, including ethnicity, age, county of residence, and HPV vaccination status. The average age of the participants was 28 (SD = 6.83). Participants self-identified as African American (n = 11), Latina (n = 7), and Asian (n = 3). Most participants reported being unvaccinated to HPV (n = 11), with a smaller group reporting partial vaccination (n = 5) or completion of the vaccine series (n = 4). One participant was unsure of her vaccination status.

3.1. Theme 1: Awareness of HPV: Determining If the Vaccine Is Right for Me

The awareness theme was based on exposures to information about the HPV vaccine and its effects on adoption, particularly within minority communities that might exhibit vaccine hesitancy. Based on participant responses, it appears these communities were influenced by misinformation, which fostered skepticism about vaccines. One representative participant emphasized the crucial role of accurate information in dispelling vaccine myths and shaping perceptions of vaccine safety among communities. Her statement highlighted the practical value of reliable sources and education in increasing vaccine uptake:

“So, I think my community in particular is really wary about all types of vaccines. Specifically, because a lot—I think they’ve been targeted by a lot of misinformation about how vaccines relate to autism.”

[P7]

This patient’s decision-making process for the HPV vaccine included personally relevant understanding of potential consequences while weighing the benefits against the risks of receiving the vaccine:

“Anything that’s going to help—I think me, personally, there is a higher of chance of cervical uterine cancers that run in my family on my father’s…I don’t see that there’s any negative, I mean, outside of like side effects, but any vaccine has those side effects—”

[P2]

For some participants, a deep mistrust of healthcare providers elicited hesitancy in receiving the vaccine. Participant 3 highlighted these feelings toward providers and the broader vaccination scheme, including skepticism that was exacerbated by the COVID-19 pandemic. She referred to healthcare providers “getting paid for them [vaccines]”, suggesting a perception that financial incentives for healthcare providers might cloud the motivations behind vaccine recommendations. The participant’s request for evidence regarding research and desire for reassurance about the vaccine’s longitudinal efficacy and benefits emphasized their hope for more evidence-based communication from healthcare providers. Lack of trust regarding the COVID-19 vaccines underscored a significant barrier to HPV vaccine acceptance, wherein a perceived lack of transparency dissuaded individuals from seeking vaccination, even when the benefits were clear.

“…Somebody gets paid for them. And so, I felt like I lost a lot of trust with-- like just given everything that happened with COVID-19. I lost a lot of trust in like vaccinations and hearing horror stories in that regard. I feel like, if any of that is withheld from me, I would most likely opt out automatically because I just do not trust the system. Like ease my trust. Like show me that you guys have been doing research on this, that this has been around for a while…”

[P3]

Additionally, the fear of experiencing adverse effects from the HPV vaccine was an insurmountable factor which influenced some women’s decisions to decline vaccination. Participant 3 also expressed concerns about potential short-term and long-term health impacts which were heightened by “horror stories” heard from her peers. Whether based on anecdotal experiences or warnings about common vaccine reactions, the word-of-mouth expressions, including from recent acquaintances, exacerbated anxieties surrounding the potential side effects of vaccination. This apprehension deterred some individuals from seeking the HPV vaccine if the perceived risk of harm outweighed protection benefits in their estimation. Addressing these fears with evidence-based information could help alleviate concerns and increase vaccine confidence.

“…Like, how does the things that we’re putting in our body, how does it affect the body? Like short term, long term. Like I’ve heard horror stories… I mean, people just sharing how like when their children got vaccinated, like it stunted development and growth and all these different things. Allergic reactions. Even—when I heard some of the warnings [unintelligible] and like with getting vaccinated as a young person, like as a child, I remember thinking like, oh, like (chuckles) I have to be careful for fever and if I feel sick for the next few days or just like all these things. And it’s like—I can’t remember what it was but it was one of the things they told me to be watching out for that it kind of scared me a bit because it was like, wait, this is potentially what could happen just from taking the vaccination?”

[P3]

3.2. Theme 2: Intrinsic Motivators for HPV Vaccine Adoption: “Like Going to the Salon and Getting Your Hair Half-Done”

For most women, the decision to receive the HPV vaccine was deeply personal. Participant 8 described incomplete vaccination as “Like going to the salon and getting your hair half-done”, a comparison that highlighted the women’s personal investment and public pride in completing the vaccine series. Furthermore, she equated the process to having her hair wholly styled, using the phrase “half-done” to convey her intrinsic motivation and commitment to achieving full protection from the vaccine.

“…that’s kind of like starting your hair but not finishing it. Like going to the salon and getting your hair like half-done. …It’s like when you start something but you don’t finish it… Like you can’t say that you did it because you only started it. Like you didn’t complete it. It’s not complete.”

[P8]

For Participant 14, a strong support group strengthened her motivation to initiate and to complete the vaccine series. She recognized the importance of having a group of peers who encouraged her to complete the series to fully protect not only herself but also the larger group.

“My friends and I are all kind of on the same page with vaccines, with, you know, like you need to get—what you need to get to protect yourself and just everyone around you.”

[P14]

Some women reported that their family was an important motivator for completing the vaccine series. Participant 4 recounted in the quote below that parental guidance encouraged her to pursue vaccination.

“I think definitely my parents for sure because, before I do anything really, I go to them for everything.”

[P4]

For other women, their intrinsic motivator was the requirement of the vaccine. For example, Participant 6 stated:

“As Hispanics, we’re only going to take a vaccine if it’s required.”

[P6]

Several women highlighted the importance of receiving the vaccine for protection and to ensure safe sexual activity for themselves and their partners. For Participant 8, who was initially unaware of HPV and its vaccine, a discussion with her physician highlighted the importance of protection against HPV and other STDs. Her quote also revealed the importance of a strong recommendation for vaccination from a physician, bringing to attention the role of healthcare professionals in promoting HPV awareness.

“When I was younger, I actually told my parents that I was thinking about having sex, and…it prompted us to calling to meet a gynecologist…She was informing me of what birth control would prevent and then was also like, you know, going into STDs, she was saying that I guess like the medical world was getting a little bit more familiar with HPV and that I should probably get a vaccination before I started having sex.”

[P8]

Several women emphasized that cultural values played a role in their uptake of the HPV vaccine. Participant 20 summarized the challenges she faced regarding being vaccinated:

“Especially like being a Black person in healthcare, I feel like we don’t really get the benefits, like we’re kind of like not cared about as much, so I feel like it’s just better to see somebody that’s more understanding to you talking about it than to see somebody else.”

[P20]

Additionally, Participant 19 discusses how cultural norms may restrict conversations about sex and sexually transmitted diseases:

“In my culture, STDs are not talked about much, but I think that having a vaccine or engaging in medical care is sort of generally approved of…I think that women of color rightfully feel quite vulnerable in the world, and I think having some sense of control over being able to protect themselves I think would be valuable to them.”

[P19]

4. Discussion

While previous studies have explored HPV vaccine hesitancy in broader contexts, such as among underserved women in urban settings [28,29] or patients receiving care at Federally Qualified Health Centers (FQHCs), our findings address critical gaps in HPV vaccination literature. By providing a state-specific, minority-focused analysis of factors influencing vaccine decision-making, this study examines the perspectives of a targeted population in a region with significant disparities in vaccine uptake.

Similarly to our study, Garcia et al. (2023) found that minority women faced several barriers regarding HPV vaccination, including limited access to quality healthcare [28]. Further, many individuals underestimate their risk of acquiring HPV or developing HPV-related cancers, primarily influenced by misconceptions and misinformation surrounding the virus and its vaccine [30,31]. In a previous study, while a majority of the participants were aware of HPV and its vaccine, only 2 of the 31 participants identified that HPV was known to cause cancer [32]. Some participants incorrectly believed that cervical cancer was caused by the number of sexual partners one had [32]. For patients who do decide to receive the vaccine, many do not understand that complete HPV protection requires a multi-dose series. This was partially reflected by our study, as 55.5% of participants who had received any dose of the vaccine were only partially vaccinated [33,34].

Increasing awareness of HPV and its vaccine alone would not guarantee vaccine uptake. Jin et al. (2023) conducted a qualitative study with healthcare workers providing HPV vaccination among African American adolescents in Shelby County, TN and revealed parental vaccine hesitancy as the main obstacle hindering vaccine uptake in African American adolescents [30]. Garcia et al. (2023) further explained that an obstacle in this population was a lack of strong provider recommendations to receive the vaccine [28]. A key contribution of our findings is its emphasis on the role of healthcare providers in vaccine decision-making, demonstrating that proactive provider engagement is a crucial determinant of vaccine uptake. Minority women in Tennessee who received the HPV vaccine series were more likely to have engaged in in-depth discussions with their providers, whereas unvaccinated participants frequently cited a lack of strong recommendations or insufficient information. These findings highlight the necessity of not only offering the vaccine but actively educating and encouraging patients to receive it. Though these findings prove to be beneficial in several populations, as providers have shared that conversations about vaccine benefits that address patient hesitancy are often hindered due to time constraints during clinical appointments [29]. Physicians were also wary of administering the HPV vaccine specifically due to perceived assumptions regarding a patient’s risk factors, such as relationship status or perceived sexual activity [29]. This ambiguity emphasizes the necessity for open and honest conversations about sexual health and HPV risks, regardless of patients’ current circumstances.

Addressing these disparities in HPV vaccination rates may require a comprehensive approach that acknowledges social, cultural, and systemic factors. Hopfer et al. (2021) determined that online resources were frequently utilized for convenience and accessibility; effective strategies to increase awareness about HPV and its vaccines included leveraging technology, such as mobile health initiatives or social media campaigns [35]. Allen et al. (2019) found that some populations prefer in-person education through clinics, workshops, and community gatherings [2]. First-generation patients who do not speak English may face additional challenges, as these individuals often require interpretation, and essential information may be conveyed differently depending on the interpreter. This language barrier often delays the pursuit of medical care because these patients fear they may not fully comprehend what their English-speaking healthcare provider might tell them. This emphasizes the need for accurate and culturally sensitive HPV vaccination information to be made accessible to all patient groups [36,37,38,39].

This thematic analysis demonstrates that those who completed the vaccine series frequently had stronger support systems, more effective communication with healthcare providers, and access to accurate HPV vaccine information. This comparative approach highlights actionable strategies for increasing vaccine uptake, including enhancing provider education, expanding community outreach, and addressing barriers to vaccine access. These findings not only reinforce the existing literature but also offer guidance for future public health interventions aimed at improving HPV prevention efforts.

5. Strengths and Limitations

The study’s qualitative design of narrative inquiry provided a perspective on the awareness and intrinsic motivators of minority women. This approach also enhances the understanding of vaccine hesitancy beyond statistical data. While previous research has identified barriers such as vaccine misinformation, low perceived risk, and fear of side effects [40,41], our findings illustrate how women personally frame their decisions. Furthermore, thematic analysis reveals the impact of personal experiences, community norms, and cultural perspectives on vaccination choices. This approach provides deeper insight into the psychological and social factors at play, offering a more nuanced perspective compared to prior studies.

Since the Advisory Committee for Immunization Practices (ACIP) expanded approval for adults aged 27–45 to receive the HPV vaccine [42], there has been a noticeable gap in research focusing on the characteristics associated with HPV vaccination in minority women, especially in Tennessee. This study, which is the first of its kind specific to Tennessee, underscores the urgent need for more concerted efforts to increase HPV vaccine awareness and uptake in minority women, particularly in southern states.

However, it is important to note that the recruitment and sample characteristics may limit the generalizability of the findings to other US minority women. The findings from this study emphasize the need for more longitudinal research to delve deeper into their intrinsic motivators for HPV vaccination in this population.

6. Conclusions

While some minority women in Tennessee had an accurate understanding of HPV and its health consequences, most were unvaccinated and had little understanding of the benefits of HPV prevention through vaccination. Those who did receive the HPV vaccination were either influenced by proactive healthcare workers or by members of their minority group at a community event. Additionally, some shared that they only received other vaccinations if they were mandated for school attendance or by other public policies. These experiences emphasize the need for educating on HPV disease and its risks, as well as promoting the benefits of receiving the vaccine. In tandem, additional advocacy from assertive healthcare providers could influence this population’s decision to get vaccinated. Overall, minority women in Tennessee could benefit from better communication regarding HPV and the HPV vaccine, as well as more direct influence encouraging them to accept vaccination.