Promoting HPV Vaccination Among American Indian Girls

In the United States, approximately 79 million people are currently infected with human papillomaviruses (HPVs), a group of more than 200 related viruses. Each year, approximately 14 million people are newly infected with HPV. Although some HPVs can cause skin warts on or around the genitals or anus, others can cause cancer. HPVs are responsible for the majority of cervical and anal cancers, 70% of oropharyngeal cancers, as well as half of vaginal and vulvar cancers and about 40% of penile cancers.

Vaccines are available to help prevent the spread of the HPV types known to cause most cases of cervical cancer, as well as those that most commonly cause genital warts. The Centers for Disease Control and Prevention recommends that children aged 11 or 12 years receive two doses of the HPV vaccine, given at least 6 months apart. Three doses are recommended for those who receive their first dose after their 15th birthday. Despite the benefits of HPV vaccination, the rates of vaccine initiation and completion are low, with only 6 out of 10 girls aged 13-17 years having received at least one dose of the HPV vaccine series in the United States. Vaccination may be particularly important among populations disproportionately affected by cervical cancer. For example, the death rates associated with cervical cancer are higher among American Indian and Alaska Natives (AI/ANs) than Whites in the Southwest region of the United States. Interventions are needed to increase HPV vaccination among AI/ANs and thus reduce the incidence of HPV infection and the risks of cervical and other cancers caused by HPV.

Promoting HPV Vaccination Among American Indian Girls is an intervention designed to increase HPV vaccination rates among girls aged 9 to 12 years through the use of mother–daughter interaction and an educational presentation directed at their mothers. The intervention, which is tailored to the Hopi culture, is based on the notion that mother–daughter interactions and the promotion of HPV vaccination increase vaccine rates. The inclusion of family members is a common cultural practice within American Indian and Alaska Native families.

Hopi mothers who have daughters aged 9 to 12 are recruited through the face-to-face distribution of flyers at community events. Additionally, scripted public service announcements are aired on local radio stations. The script invites mothers to attend events called "Hopimamant Itàaqatsiy Öqalni'yyungwa," or "Hopi Girls Sustain the Hopi Way of Life." Mothers who are interested in learning more about the program are invited to contact project staff.

Mothers who decide to participate attend an event with their daughters. The intervention begins with social activities—dinner and entertainment (e.g., singing, dancing)—that include the mothers and daughters together. Subsequently, mothers and daughters separate and participate in different activities. Mothers attend a 30- to 40-minute educational PowerPoint presentation on HPV that is led by a Hopi health educator. The presentation, which addresses topics such as HPV and cervical cancer, sexually transmitted infections, signs and symptoms of HPV, and the HPV vaccination schedule, is tailored to the Hopi culture with images of AI/AN people and statistics and resources specific to this group. The daughters participate in an alternative activity, which may be health related.

-- Time for recruiting mothers and their daughters, which varies by available resources
-- 1 hour for the dinner and entertainment and 30 to 40 minutes for the session when mothers receive an HPV presentation and daughters participate in an alternative activity

The intervention targets Hopi mothers and their daughters aged 9 to 12 years. Although it was developed specifically for use with members of the Hopi Tribe, the intervention could be modified and used with other Native populations.

This intervention can be implemented in community settings.

Required resources to implement the program include the following:
-- Educational Pamphlet
-- Educational PowerPoint presentation
-- Flow Chart
-- PSA Radio Recruitment Script
-- Recruitment Flyer

A cluster-randomized controlled trial with members of the Hopi Tribe in Arizona compared the effect of the intervention with that of a comparison condition (a diabetes educational presentation) on initiation of HPV vaccination. Study recruitment was conducted in March and April 2012. Interested women were screened for eligibility and enrolled if they were at least 18 years old, were a mother or female legal guardian of a girl aged 9 to 12 years old, and were enrolled in the Hopi Tribe and living on the reservation. All 12 Hopi villages were grouped into four geographic clusters that were then randomly assigned to the intervention group (two) and the comparison group (two). To implement the intervention and comparison conditions, two or three educational events were offered for each cluster, based on village size, for a total of 11 events. Both the intervention and comparison group participants attended events with dinner and entertainment, but the educational presentation given to comparison group mothers focused on healthy nutrition, physical activity, and diabetes prevention.

A total of 97 mothers were recruited for the study. The average age of participating mothers was 42 in the intervention group (n=43) and 40 in the comparison group (n=54). Sixty percent of the mothers were married, 43% had a high school education or less, 73% were employed, and 34% were not familiar with HPV. Forty-seven percent of daughters were 9 or 10 years old, and 52% were 11 or 12 years old. At baseline, the mothers' demographic characteristics were similar across groups in all respects other than income; mothers in the intervention group had significantly lower household incomes than mothers in the comparison group.

The main outcome- vaccination initiation was assessed through a survey about 11 months after the intervention was delivered. The survey was tailored based on the number of vaccine doses received at baseline (zero, one, or two doses). (Those who had already received all three doses at baseline did not receive a follow-up survey and thus were not included in the analyses.) Study staff called mothers and administered the survey by phone, calling up to three times if needed over a 2-week period. For mothers who were unreachable by phone, a follow-up survey was mailed with a self-addressed stamped envelope. Those who remained unresponsive were sent a second follow-up by mail 2 weeks later.
 

• Among daughters who had received no HPV vaccinations at baseline, those in the intervention group had a significantly higher rate of HPV vaccination initiation (one or more dose) at 11-month follow-up than did those in the comparison group (p=.003).