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HPV Vaccination: Impact of Culture and Language on Initiation, Completion


English- and Spanish-speaking parents cited widely differing reasons for avoiding vaccination for their eligible daughters or failing to ensure the 3 doses were received.

Sean O’Leary, MD is an academic Pediatric Infectious Disease consultant, but at IDWeek 2013, in San Francisco, he talked more like a public health expert-or a sociologist. His study, presented on October 4, looked at a low socioeconomic status group in the Denver, Colorado area and teased out predictors for non-initiation and non-completion of the human papilloma virus (HPV) vaccine series in girls (per current recommendation). The vaccine is a covered benefit under two large urban “safety-net” health systems in Colorado (80% of enrollees receive Medicaid). Low-income families are at highest risk for cervical cancer, yet have shown the lowest rates of adoption of this cancer-preventing vaccine. But within that group, what factors influence which families will access the vaccine? 

The inclusion criterion for this survey study was evidence in administrative data for non-initiation (NI) or non-completion (NC) of the recommended 3-dose series for HPV vaccination in girls ages 12 to 15. Parents were recruited to participate in one of the following:
• Spanish-speaking NI (10 parents): 25-40 minute telephone interview
• Spanish-speaking NC (10 parents): 25-40 minute telephone interview
• English-speaking NI (11 parents): 2-hour focus group
• English-speaking NC (10 parents): 25-40 minute telephone interview

Among English-speakers (both NI and NC), vaccine safety concerns, a low perceived risk of HPV infection, and distrust of government and/or medicine were the primary barriers to vaccination. Surprisingly, some parents of NC also reported that safety concerns emerged only after their daughter had received the first dose.

In contrast, Spanish-speaking parents were not concerned about safety of the vaccine, and expressed a high degree of trust for their doctors advice, but claimed that their doctors had either not encouraged HPV vaccination (NI) or had not explained the necessity of completing the series (NC). Only Spanish-speaking NI cited concerns that vaccination would encourage sexual activity.

It’s a small descriptive study, and Dr. O’Leary describes the cohort as a “convenience” sample of those who responded, so selection bias is definitely a concern.

My own curiosity is whether income, rather than language or culture, is the real predictor, but income information was not available in this study. After controlling for income, does the difference in perceptions and belief between English and Spanish speakers disappear? This study cannot address that, but it does raise concerns about poor communication with families whose primary language is not English, and underscores the importance of interpreter services in realizing the public health benefits of initiatives like HPV vaccination.


O’Leary S, Barnard J, Lockhart S, Albright K, et al. Exploring the reasons for non-initiation and non-completion of the HPV vaccine series among parents of adolescent girls in a low SES population. Abstract presented at: IDWeek 2013; October 3, 2013; San Francisco, Calif. Abstract # 140. View on IDWeek 2013 Web site.

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