Hispanic women in the United States have higher rates of cervical cancer (1) than women in other racial/ethnic groups. In Puerto Rico, cervical cancer is the 6th most commonly diagnosed cancer among women (2). Two vaccines, Gardasil and Cervarix, prevent infections by high-risk human papillomavirus (HPV) types, which cause most cervical cancers (3). Gardasil, approved in 2006, is recommended for both young men and young women, and protects against HPV types 6, 11, 16, and 18; Cervarix, approved in 2009 for young women, protects against HPV types 16 and 18.

Rates of HPV vaccine initiation (51%) and completion (21%) are lower among girls aged 11 to 18 years in Puerto Rico (4) compared with young Hispanic women in the mainland United States (62.9% initiating and 59.3% completing the series). This disparity exists despite availability of free vaccination for children aged 11 to 18 years in Puerto Rico through several programs: Vaccines for Children (VFC), the Puerto Rican governmental health insurance plan (Mi Salud), and State Law no. 255, which mandates health insurance coverage of the HPV vaccine for girls and boys aged 11 to 18 years. Among US Hispanic women in the “catch-up” age range (19–26 years), HPV vaccination initiation rates (18.7%) are even lower than among adolescents (5). In Puerto Rico, programs for free vaccination do not cover women aged 19 to 26. Some, but not all, private insurance companies cover vaccination for women in the catch-up age group. Mi Salud participants, the uninsured, and those with medical insurance not covering the vaccination for this age group, can obtain it at a cost of $100 to $110 per vaccine dose at 6 vaccination centers across the island. Thus, access to vaccination among women aged 19 to 26 may be influenced by cost barriers.

Parental psychosocial factors that influence vaccination are knowledge (6–8), physician recommendation (9,10), and the belief that vaccination will protect daughters against genital warts and cervical cancer (6,10). Studies among women aged 18 to 26 (11,12) and 19 to 26 (13) report that knowledge and awareness of HPV (11), beliefs and attitudes about HPV vaccine (13), access to transportation (12), and prioritizing health over other daily responsibilities (12) are associated with vaccine uptake.

Research among Hispanic mothers and daughters in the United States (6,14) revealed key predictors of vaccine uptake, but information about psychosocial factors influencing vaccination among women in Puerto Rico is not available. Although young women aged 19 to 26 may have more autonomy in HPV vaccine decision-making than do underage girls, they may still rely on parental input or financial support for vaccination. The purpose of this study was to explore factors influencing HPV vaccine initiation decisions by mothers and daughters in Puerto Rico.

Recruitment announcements were posted throughout hospitals and clinics at San Juan Medical Center and in communities identified through our outreach network (15). We recruited young women aged 16 to 26 and mothers of daughters in the same age range. Although recruitment efforts targeted fathers and mothers, except for one father, all participants were mothers. We removed the father’s data from the analysis for consistency and analyzed only data from mothers. Other eligibility criteria included daughters’ knowledge of their own HPV vaccination status, mothers’ knowledge of their daughters’ HPV vaccination status and no history of cervical cancer for either group. Among 44 eligible mothers and young women, 30 (68%) agreed to participate. Participants were assigned to a daughter- or mother-focus group and were stratified by HPV vaccination status (daughter had at least one HPV vaccine, and those never vaccinated). All mothers had daughters that participated in the young women’s groups. However, some young women did not have their mother in the parents’ groups. The institutional review boards of the University of Texas Health Science Center and the University of Puerto Rico Medical Sciences Campus approved the study protocol.

We conducted 7 focus groups during April through June 2010: 4 with young women (n = 21) and 3 with mothers (n = 9). Three groups consisted of unvaccinated daughters (n = 16) and one group consisted of vaccinated daughters (n = 5). Two parental groups had unvaccinated daughters (n = 6) and one group had vaccinated daughters (n = 3). Group discussions were held at an academic institution in the San Juan Medical Center. The study team adapted an existing interview guide (Box 1) from a previous study (6). The facilitator described the study and obtained informed consent. Women younger than 18 years provided a parent-signed informed consent and their assent to participate. All participants completed a short demographic questionnaire. Female facilitators conducted the 1-hour focus groups in Spanish. Following the discussion, participants received educational materials about HPV and cervical cancer, along with $20 as compensation. Focus groups were audio-recorded, transcribed, and entered into Atlas.ti (ATLAS.ti GmbH) for analysis.

The lead author and 3 coders read all transcripts and began coding by using a constant comparison method, consistent with a grounded theory approach (16). Coders read and coded the same transcript, and then discussed identified themes and produced a base set of codes to use for the remaining transcripts. The analysis team met biweekly to discuss new themes and to come to consensus on new codes and coding discrepancies.

The analysis of the focus group transcripts allowed us to identify several emergent themes related to vaccine uptake: 1) low knowledge about cervical cancer, HPV, and the HPV vaccine; 2) inconsistent beliefs about susceptibility to HPV infection and cervical cancer; 3) misconceptions about vaccine effectiveness; 4) concern about vaccine safety and side effects; 5) concern that the vaccine promotes sexual disinhibition; and 6) lack of insurance coverage and overall cost of the vaccine (Box 2). Daughters’ mean age was 20.4 years (standard deviation [SD], 3.8 y) and mothers’ was 47.9 years (SD, 5.5 y). Most daughters had completed 1 or more years of college education (67%); 86% of mothers had a bachelor’s or advanced degree. All daughters had health insurance. Slightly more than half (55%) of participants reported a family income below $40,000 annually.

This study explored psychosocial factors influencing the HPV vaccination decisions of mothers and daughters living in Puerto Rico. Although several of our findings are similar to those of other studies (6,14,17), we identified unique factors and possible differences in the degree of importance for some of the common ones. For example, despite high levels of education and income among our participants, their knowledge about HPV and HPV vaccination was low, especially among mothers. Additionally, their concerns about vaccine efficacy and, to some extent, safety seemed to be associated with their perception that the HPV vaccine had neither been promoted in Puerto Rico nor recommended by their providers.

Provider recommendation, a factor that influences vaccine decisions (17,18), may be of particular relevance in Puerto Rico. Studies on role preference in health care decision-making show that Hispanic patients often prefer that providers take the lead in making health care decisions (19). This situation may translate into less willingness to ask a provider to vaccinate their daughters and less willingness to engage in health-related behaviors without explicit recommendations from providers.

Mothers expressed reluctance to vaccinate younger daughters and did not understand the benefit of HPV vaccination before initiation of sexual activity. Maternal concerns that HPV vaccination would promote sexual disinhibition have been reported elsewhere (20,21). In a study with Latina parents in 3 different regions of the United States, concern about HPV vaccination promoting sexual disinhibition ranged from 11% in Los Angeles to 60% in Seattle (17). Prior work also has shown that this concern is more likely among older parents and those reporting conservative views (4). However, increased knowledge about the HPV vaccine decreases the likelihood of having this belief (21).

Mothers also expressed concerns regarding vaccine efficacy and safety. Other studies with Hispanic populations reported similar concerns (6,8,10). Low immunization rates overall in Puerto Rico (measles, mumps, and rubella [MMR], 85.2%; diphtheria, tetanus, and pertussis [DTaP], 81.9%; varicella [chickenpox], 88.7%) (4) may be related to concerns about the overall safety of vaccines and should be considered a contextual factor in mothers’ reluctance to have their daughters vaccinated for HPV. Although some daughters, particularly unvaccinated ones, had concerns, they generally had a better understanding of the need for vaccination and recognized the benefits of following recommended HPV vaccination guidelines.

This study has some limitations. Given the nature of qualitative inquiry, results are not generalizable to all women in Puerto Rico. Additionally, participants were of higher socioeconomic status than the general population in Puerto Rico. For 2008 through 2012, the annual median household income in Puerto Rico was $19,515 (22), whereas in our study 75% of the young women and all of the mothers had a yearly income of $20,000 or higher. Although 67% of the young women in the groups had at least 1 year or more of college education, only 27.8% of young people aged 18 to 24 in Puerto Rico had completed high school. Nevertheless, even with higher education and income levels, knowledge of HPV and the vaccine was still low. Young women and mothers may now have different or additional concerns than participants in our study in 2010. However, since HPV vaccination rates are still low, probably for many of the same reasons (4), we believe our study findings provide a valuable contribution to the factors associated with low levels of HPV vaccination in Puerto Rico.

Our findings are consistent with those of other studies, yet some factors varied in the degree of importance for Puerto Ricans. Increasing the level of HPV vaccination may not necessitate new interventions that are vastly different from those developed for other groups. Instead, moderate adaptation of interventions may make them more relevant for Puerto Rican women. For example, given mothers’ doubts about vaccine efficacy due to low recommendation and promotion of the vaccine, messages focusing on vaccine efficacy, recommendations from providers, and increased promotion of the HPV vaccine may be warranted. Additionally, because mothers seem to be involved in the vaccine decision for economic or cultural reasons, interventions focusing on communication between mothers and daughters about HPV may increase vaccination. Modifying promotional materials to match them with Puerto Rican culture may also be warranted. A recent study (15) that explored the role of ethnic identity on attitudes toward HPV vaccine advertising noted that Puerto Rican participants did not identify with many of the HPV vaccine campaigns because the actors’ facial characteristics and language were not Puerto Rican. Participants also did not feel at the same risk levels as the individuals portrayed in the advertisements (15).

Our study is the first to provide insight into common psychosocial barriers affecting HPV vaccination in Puerto Rico and underscores the need for increased education about HPV vaccination, provider recommendations, and access to low-cost vaccines, similar to findings reported from other studies (17,23–26). Future interventions should address knowledge regarding HPV vaccination effectiveness and safety, the rationale behind HPV vaccination for young age groups, and the potential benefits for vaccinating young women in the catch-up age range. The Community Cancer Control Outreach Program, the Cancer Center Coalition at the University of Puerto Rico, and the Puerto Rico Comprehensive Cancer Center are implementing initiatives that translate such findings into messages and strategies to promote HPV vaccination throughout Puerto Rico.