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WOMEN’S REPRODUCTIVE HEALTH, 1(2), 120–137, 2014
Copyright C
Society for Menstrual Cycle Research
ISSN: 2329-3691 print / 2329-3713 online
DOI: 10.1080/23293691.2014.966034
Social Networks Influence Hispanic College Women’s HPV
Vaccine Uptake Decision-Making Processes
Dionne P. Stephens
Florida International University, Miami, Florida, USA
Tami L. Thomas
Emory University, Atlanta, Georgia, USA
This qualitative study was designed to assess current and preferred social networks that influence
human papillomavirus (HPV) vaccine decision-making in a sample of Hispanic college women. Indi-
vidual, semistructured interviews were conducted with 41 Hispanic college women attending a large
southeastern Hispanic-serving institution. Television commercials and discussions with mothers were
found to be the most influential social networks for current HPV vaccination beliefs. Internet sites,
close family members, and healthcare providers’ communications were preferred social networks
for HPV vaccine information. Perceived accessibility and sense of comfort influenced the order in
which these social networks’ communications would be accepted. Findings suggest that Hispanic
college women utilize specific social networks to gather information and make decisions about HPV
vaccination. Continued efforts are needed to promote further understanding of the purpose of the
HPV vaccine via these preferred sources of information.
Keywords HPV vaccine, Hispanic women, health-seeking behaviors
The vaccination of college-age women against human papillomavirus (HPV) infection is a critical
public health goal given that 50% of college women are estimated to be infected (Lopez &
McMahan, 2007; Sandfort & Pleasant, 2009; Winer et al., 2003). It is important to consider
the sources of information about vaccination used by college women because research has
identified specific postsecondary school sexual contexts and values that often increase women’s
risk for HPV transmission. High-risk sexual behaviors, inconsistent contraceptive usage, and
coercion/violence, which are often normalized in college settings, are associated with higher rates
of HPV acquisition (Prinstein, Meade, & Cohen, 2003; Sandfort & Pleasant, 2009). According
to the Centers for Disease Control and Prevention, even with the availability of an HPV vaccine,
uptake and vaccine series retention among college women remains below 40% (CDC, 2010).
Prior research has shown that a blanket approach to health communications regarding HPV
vaccine is ineffective, because subgroups of college women utilized different social networks
for information depending on their cultural values, sexual orientation, or socioeconomic identity
Correspondence should be sent to Tami L. Thomas, PhD, Emory University, Nell Hodgson Woodruff School of
Nursing, 1520 Clifton Road NE, Atlanta, GA 30322, USA. E-mail: tami.thomas@emory.edu.
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HPV VACCINE HISPANIC COLLEGE WOMEN 121
(Eisenberg, 2001; Pruitt & Schootman, 2010; Watts, 2008). Still, HPV and HPV vaccination
studies of college women’s experiences continue to draw primarily from European American
and African American samples. In fact, no studies we can find have specifically examined
Hispanic college women’s health literacy or communication about HPV issues, although these
women represent the largest group of racial/ethnic minorities on 4-year college campuses in the
United States (Fry & Lopez, 2012). This omission in research is of particular concern given
that the highest burden of HPV-related cervical cancers occurs in young adult Hispanic female
populations (Vanslyke et al., 2008; Scarinci, Garc ´
es-Palacio, & Partridge, 2007; Watts et al.,
2008). Thus, there is a need to identify whom Hispanic college women trust and rely on to
provide information that will protect them against HPV. To address this void in the literature,
we utilized social network theory (SNT) to identify Hispanic college women’s communication
networks when they are seeking HPV and HPV vaccine information (Berkman, 2000). A social
network is defined as the social structure of relationships around a person, group, or organization
that affects beliefs or behaviors (Berkman, 2000; Simons-Morton Haynie, & Noelcke, 2009).
SNT asserts that the relationships and ties that an individual has with various social networks
play a significant role in informing behavior.
HPV VACCINATION
HPV vaccines have been proposed as an important tool in the primary prevention of cervical
cancer. In 2006, the FDA approved, for women and girls aged 9 to 26 years, an HPV vaccine that
protects against the strains responsible for over 90% of all genital warts and 70% of all cervical
cancers (Munoz et al., 2010). It consists of a series of three vaccines given over a course of 6
months (Allen et al., 2012). The vaccine has been shown to be effective, safe, and well tolerated
among adolescent and young adult women (Munoz et al., 2010).
Despite the availability of the vaccine and evidence that college students have unique access
to sexual health education and higher levels of knowledge about sexually transmitted diseases
(STDs) than their peers do, several studies have shown that their knowledge about HPV and HPV
vaccination is inadequate (D’Urso, Thompson-Robinson, & Chandler, 2007; Sandfort & Pleasant,
2009). A lack of HPV vaccination knowledge has implications for sexual health outcomes. For
example, studies of college and community-based Hispanic female samples indicate that, although
they were willing to be vaccinated, they had low levels of retention over the required three courses
of injections (Brewer & Fazekas, 2007; Hopfer & Clippard, 2011; Pruitt & Schootman, 2010;
Vanslyke et al., 2008; Watts et al., 2008). In fact, vaccine uptake among women at this age is below
28% (CDC, 2008), and rate of retention through the remaining required two rounds of vaccination
is even lower (Pruitt & Schootman, 2010). Researchers have pointed to lack of knowledge as
an important contributing factor in college women’s HPV vaccination uptake decision-making
processes.
SOCIAL NETWORK THEORY
One step toward addressing Hispanic college women’s low HPV vaccine knowledge and vaccine
series completion is the identification of sources of information that influence their decision-
making processes. In designing the present study, we were guided by social network theory
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122 STEPHENS AND THOMAS
(SNT) (Berkman, 2000; Berkman & Glass, 2002; Simons-Morton et al., 2009), which focuses on
how relationships between people influence health communications. SNT also defines how these
relationships might comprise the feelings people have for each other, the exchange of information,
and/or more tangible exchanges of resources (e.g., money for medicine, health insurance). In the
context of the present study, SNT was used to help identify what social networks, and who within
them, influence Hispanic college women’s HPV vaccine decision-making processes.
Although social networks have different levels of influence for different issues, they each
require the utilization of three key processes: socialization, selection, and social norms. Social-
ization refers to the ways in which social networks teach individuals to think, feel, and behave
(Simons-Morton et al., 2009). Whether direct or indirect, socialization processes communicate
behaviors that reinforce uniformity according to each social network’s value system. The ways in
which an individual chooses to accept or reject information communicated through socialization
is evidenced through the selection process. People tend to associate or accept information from
those who share common interests, views, or behaviors, particularly when these associations
support those behaviors in which they wish to engage or are engaging (Simons-Morton et al.,
2009). Finally, social norms are implicit in the development and outcomes of socialization and
selection processes. As the customary rules of behavior that coordinate interactions with one
another, social norms vary and evolve through time and among social networks. This continuous
change requires an individual to communicate, incorporate, and negotiate values given to social
networks’ socialization and selection processes (Simons-Morton et al., 2009). Through this triadic
process, appropriate health-related behaviors are communicated to people based upon their sense
of attachment to particular social networks (Berkman, 2000; Berkman & Glass, 2002). Thus,
knowledge about people’s attachments could contribute to our understanding of the influence of
social networks’ communications about appropriate health behaviors, an important goal of those
seeking to increase HPV vaccine uptake in Hispanic college student populations.
Although few studies have exclusively focused on social networks’ role in HPV vaccine
decision-making processes, several researchers have explored the roles of healthcare providers,
family, and media outlets in the communication of information. These studies provide impor-
tant insights, but they focus primarily on European American and African American college
samples; none have drawn exclusively from Hispanic college samples (Lopez &, McMahan,
2007; Munoz et al., 2010; Sandfort & Pleasant, 2009; Winer et al., 2003). Similarly, Hispanic
community-based samples do not capture the unique college contextual experiences that put these
women at risk. This is problematic, given that the number of Hispanic women attending postsec-
ondary institutions has increased to the point that they are now the largest ethnic minority group
attending college in the United States (Fry & Lopez, 2012). The shift in college campus popula-
tions’ diversity and Hispanic women’s high risk for HPV infection challenge researchers to in-
crease knowledge about this population’s sexual health needs, particularly their HPV vaccination
beliefs.
METHOD
Because our goal was to identify Hispanic college women’s subjective perceptions and experi-
ences with HPV vaccine messaging, social networks’ influence, and decision-making processes,
a qualitative approach was used. Qualitative approaches are appropriate for exploring this topic
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HPV VACCINE HISPANIC COLLEGE WOMEN 123
because of they can identify meaningful conceptual distinctions tied to individual identify factors,
including gender, race, and sexuality (Few, Stephens, & Rouse, 2003).
Participants
Participants were recruited from a Hispanic-serving institution’s psychology research pool. In-
dividuals were screened for eligibility prior to scheduling their interviews; criteria included
self-identifying as Hispanic, female, and between 18 and 24 years of age. A total of 41 women
with a mean age of 19.8 participated in the study. All participants self-identified as ethnically
Hispanic and racially White. Participants identified their familial national origins as Cuban
(N =22), Colombian (N =12), Argentinean (N =2), and other nationalities (N =5), includ-
ing Brazilian, Dominican, Mexican, Nicaraguan, Puerto Rican, and Venezuelan. Although six
were born abroad, only two women had lived outside the United States for more than 5 years.
The participants self-identified as heterosexual (N =39) or bisexual (N =2), and the majority
(N =36) were single at the time of the interviews. The participants’ average number of sexual
partners in a lifetime was 1.7; 18 participants had not yet had sexual intercourse. A total of 14
women (32%) had already started or completed the HPV vaccination series.
Interview Procedure
Three female research assistants who self-identified as Hispanic conducted the individual inter-
views at a time selected by the participants. After they had read the letter of consent approved
by the university’s Institutional Review Board, the participants completed a demographic ques-
tionnaire and an HPV-vaccine-knowledge survey. Anonymous surveys given to each participant
included demographic questions (age, residence, class standing, income, and race/ethnicity), sex-
ual activities (numbers of partners; types of sexual activity, including oral sex, anal sex, and
masturbation), and HPV-specific items adapted from the previously validated Parental Human
Papillomavirus Survey (PHPVS; Thomas et al., 2013). The PHPVS was developed in English
and Spanish to evaluate parental knowledge, beliefs, and correlates of HPV vaccination. The PH-
PVS contains 28 Likert-type items and maintains high internal consistency across all subscales
(perceived severity and perceived vulnerability of HPV; perceived benefits and perceived barriers
to vaccination), with a high total Cronbach’s alpha (.96) that was not increased by item deletion
(Thomas et al., 2013). For the present study, the instrument was modified for college-aged young
adults and had only 27 items. The modifications included the removal of five previous items and
the addition of four new items. The Cronbach’s alpha for the modified PHPVA for these partic-
ipants was only .21. However, for the analyses herein, participants’ responses to the modified
HPV items were considered separately as potential predictors of intent to vaccinate, so the low
reliability did not impact our conclusions.
Interviews were conducted in a private conference room; each session was audio taped, and
lasted between 15 and 65 minutes. Each participant provided a pseudonym to be used in the
interview and to label their transcripts. A questioning route for these interviews was developed
using SNT constructs, and it provided a framework for developing and sequencing a series of
semistructured, yet flexible, questions. Each interview began with questions focused on establish-
ing HPV vaccination knowledge and beliefs. Some questions included: Have you heard about the
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124 STEPHENS AND THOMAS
HPV vaccine? What do you know about the HPV vaccine? Would/did you get the HPV vaccine?
Where would you go to find out more about the HPV vaccine when making your decision?
Data Analysis
A modified version of constant comparative methods of data analysis was used to identify patterns
of healthcare decision-making processes in the context of HPV vaccination (Corbin & Strauss,
2007). Three research assistants transcribed the interviews; the principal investigator (PI) and
two additional research assistants verified the completeness of the transcripts, accuracy of the
discussion content, and high quality of transcription.
Data collection and analysis proceeded simultaneously, using a modified version of the constant
comparative method (Glaser & Strauss, 1967). We formed categories, established the boundaries
of each category, assigned segments to categories, summarized the content of each category, and
then sought to find negative evidence in order to discern conceptual similarities and refine the
discriminative power of the categories and thereby discover true patterns in the data (Strauss &
Corbin, 1990). The PI and coinvestigator (CI) constructed a preliminary coding framework after
in-depth reading of the transcripts. SNT constructs, including social context, levels of influence,
and social influence, guided this processes. The PI and CI did not label the SNT themes identified
at this stage of the data analysis but derived them from the data. Lower level codes (segments)
were categorized according to their similarities or differences; these categories were refined, and
the content was summarized and developed into the highest level categories, then categories were
collapsed to develop constructs. To do this we first coded sections of the text by issue or theme,
and additional codes were added as new themes emerged. The PI and CI separately read all the
transcripts in their entirety, then coded and organized the data to identify key themes related
to HPV vaccination knowledge and attitudes and sources of HPV vaccination information. One
graduate research assistant also independently coded the data and created a comprehensive list
of themes that she identified in the data. Later, the PI, CI, and graduate research assistant met as
a group to discuss and further refine each set of themes, resolve differences, and reach consensus
on a coding scheme. Theoretical insights that emerged during data collection and analysis or
participant feedback were recorded into written logs.
Discrepancies were resolved by first revisiting and reviewing the data, and then through
group discussion. In our analysis, several strategies to increase trustworthiness and validity
were implemented. We had regular discussions that focused on current research in the areas
of (a) Hispanic women’s sexual identity development, (b) HPV and HPV vaccination, and (c)
healthcare decision-making processes in order to question analyses critically and to consider rival
explanations throughout the research process (Marshall & Rossman, 2006). To ensure validity,
all of the study team members summarized, reviewed, and agreed on the key themes.
RESULTS
Current HPV Vaccination Knowledge and Attitudes
More than one third of the participants had not yet had sexual intercourse, which made them
eligible for vaccination. However, their self-perceptions about their own HPV and HPV vaccine
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HPV VACCINE HISPANIC COLLEGE WOMEN 125
TABLE 1
Hispanic College Women’s Perceptions of HPV and HPV Vaccine Knowledge
Perception of HPV Knowledge N %
Very knowledgeable 5 12.1%
Fairly knowledgeable 7 17.0%
Somewhat knowledgeable 16 39.0%
No knowledge 13 31.7%
Perception of HPV Vaccine Knowledge
Very knowledgeable 2 4.8%
Fairly knowledgeable 3 7.3%
Somewhat knowledgeable 23 56.0%
No knowledge 13 31.7%
knowledge were mixed. The majority of the women reported on their demographic survey that they
were “very” to “somewhat” knowledgeable about HPV (see Table 1). The degree of knowledge
decreased when they were asked specifically about the HPV vaccine; most women reported that
they were “somewhat” knowledgeable or had “no knowledge” (see Table 1). However, when
asked to detail what they knew about the HPV vaccine in the interviews, all but one of the women
made statements that indicated that they were unsure about the vaccine’s purpose and how it
worked. During the interviews, the majority of women “guessed” that it prevented HPV and
protected them against developing cervical cancer.
Only one of the 14 women who had already started or completed the vaccine series selected
the “very knowledgeable” option and was able to provide accurate information about the HPV
vaccine during the interview. Eleven reported that they had somewhat or no knowledge about the
HPV vaccine. Their lack of information was further made evident when asked to share what they
knew about the HPV vaccine during their interviews:
Maylin: And I know I got the vaccine. Um, there were 3 shots? It doesn’t protect you from cervical
cancer but it protects you from HPV? I guess that’s all I know.
Sabrina: I know it’s only for women—they told me that when I got it. It’s mainly for people who
have sex—right? I don’t know.
Cantera: It hurts—is that the one that’s in three doses? I got it when I was in high school.
Social Networks that Currently Provide HPV Vaccination Information
Although social networks, such as peers and healthcare providers, were noted by some women,
television and conversations with their mothers emerged as the most mentioned social networks
that provided these women with initial information about the vaccine (see Table 1).
Television
The majority reported hearing about the vaccine via television programs and commercials. All
of these women remembered the Gardasil commercials; the “One Less” slogan was particularly
memorable.
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126 STEPHENS AND THOMAS
Maricel: It was, like, a TV show—I don’t remember. But it was, like, students and they were being
treated at a high school. I saw the Gardasil commercial—but I don’t remember and don’t know how
it works and what it does.
Woo: I’ve seen the commercial. You know “one less,” they keep saying it—”one less,” with those
girls skipping and the mother saying she was going to take her daughter to get it. And it’s for women
to stop cervical cancer. “One less woman with cervical cancer.”
In addition, four women stated that news coverage about the HPV vaccine shaped their
perceptions of it. The information they recalled was brief and primarily focused on vaccine
availability. The reports’ linking of HPV to cervical cancer prevention was most salient; they
perceived this link as important because it was being covered in the news. However, these women
were unable to recall further details about the news item or the HPV-specific content.
Mothers
Although the women named television, and particularly Gardasil commercials, as providing
their initial awareness about the HPV vaccine, mothers’ messages about the HPV vaccine were
also viewed as important. Mothers were specifically identified as playing a key role in these
women’s HPV vaccination uptake decision-making process. In fact, 9 of the 14 vaccinated
women reported that they did so because it was approved of or encouraged by their mothers.
Rose: I’m not completely sure what it was. I know that it was to prevent, like, cervical cancer. My
mom’s the one that, like, knows about that, because she’s the one that was, like, “I know that it just
came out like it was new.” And so, like, the doctor said that they had [the vaccine] available so she
told him to, like, for me to receive it.
Kim: I got the vaccine—but wouldn’t have gotten it if my mother wasn’t involved, telling me about
it.
Joanna: I just went to the doctor one day and the doctor mentioned it to me and my mom. And my
mom said, “you should get it”—that was it.
Preferred Sources of HPV Vaccine Information
Although participants reported their mothers as influential social networks for HPV vaccine
information, the information mothers provided was viewed as inadequate. The women in the
study reported that they did not discuss details about the vaccine with, or gain what they thought
was comprehensive HPV vaccination knowledge from, their mothers. Nor did they think that
television messages provided them with the information they wanted to know about the vaccine’s
impact, potential risks, processes, and overall health impact. The majority agreed that they
needed more information about HPV and the HPV vaccine. To learn this information, these
women reported that they would turn, in the following order, to the Internet, family members,
and healthcare providers (see Table 2).
Internet
Because of its convenience and easy accessibility, the Internet was the first social network
these women would turn to if they wanted more information about the HPV vaccine. Participants
reported it as the easiest and quickest way to find answers to questions about their health.
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HPV VACCINE HISPANIC COLLEGE WOMEN 127
TABLE 2
Hispanic College Women’s Perceptions of HPV Vaccine Social Networks
N%
Current HPV Vaccine Information Social Networks
Television 21 51.2%
Mothers 18 43.9%
Healthcare providers 2 4.8%
Preferred HPV Vaccine Information Social Networks
Internet websites 19 46.3%
Family members 13 31.7%
Healthcare providers 9 21.9%
Accessing the Internet was a part of their lifestyle and daily activities, so it was viewed as a
normal space through which to seek more HPV vaccination knowledge.
Dyanna: Since I’m kinda like busy and hectic, I would probably—like tonight—go online and like
search up [HPV vaccine information on] Wikipedia. Because, like, if I actually had time I would
go to the health center because I know that they do all that stuff and that they can actually tell me
everything that I need to know [about the vaccine]. But since I really don’t have time I’ll use the
Internet.
Kim: Actually, I’m going to check [HPV vaccine information] to find out everything on my [cell]
phone when I leave here! I guess I can just Google it or something.
Vic toria : I would only check Gardasil’s website [for HPV vaccine information] just because I know
anybody can post anything. I mean, everything else I would take in as opinion because I know that . . .
but I think if other people were looking, they should only look at Gardasil’s website.
Internet search engines, health-related websites, and the Gardasil website were most often
cited as their preferred online social network setting. Search engines, such as Google, were stated
as useful for their ability to provide a broad set of information. However, the women expressed
concerns about the accuracy and quality of the website information, and pointed out that “anyone
can post information.” As such, established health-related websites, including that produced by
the Merck Pharmaceutical Company (advertising the Gardasil vaccine) and the CDC website
were viewed as the most likely to provide accurate information.
Family Members
Family members were the second HPV information social network choice of participants.
As individuals who would be concerned about these women’s well-being, family members
were viewed as important, supportive sources of HPV vaccination information. The choice of
a particular family member was based on the closeness the women had to the person and how
they felt the person would respond to sexual-health-related questions. The women also noted that
certain family members would be avoided for fear of negative reactions due to the sensitive and
sexual nature of HPV.
Wendy: I would ask my family. The thing is my family is very bias [sic] toward premarital sex and
not having it. So why would you need [the HPV vaccine]? The majority of my family is like that.
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128 STEPHENS AND THOMAS
But my mother was like “you should do it”—but my mother is different from the rest of my family
[giggles].
Louisa: My family’s opinion would be important. Well my mom has an uncle that’s a gynecologist
and he wasn’t really sure about [HPV vaccination] because it’s really new. So he said to wait, so my
family was like wait.
La Bella: I would ask [family] for information. There’s a history [of cervical cancer] in my family so
they’ve been wanting me to get the vaccine.
Sophy: My sister got it before I did, my younger sister. So then I just went to the doctor and I did it
as well.
Healthcare Providers
Finally, healthcare providers were the third preferred social network for HPV information.
It is important to note that healthcare providers were perceived as the most reliable sources
of accurate information, despite being the third choice for information. The majority of the
participants explained that the medical proficiency and up-to-date knowledge these providers are
assumed to have made them the most appropriate informants about the HPV vaccine.
Abella: I would go straight to [campus health clinic] or if my general doctor can give me the
information I would go to him. I would just go to somebody that actually knew exactly what it is, the
effect, the symptoms, and everything that comes along with it.
Maria: My doctor just told me. I mean she said, “Why not, it’s not going to hurt you in any way.” So
I figured why not—she knows what’s best.
Woo: My gynecologist—she told me about it. I don’t remember what she said. But if I want to know
more I would ask her. She deals with this stuff everyday so she’ll know all the current updates.
Although the participants attached importance to healthcare providers’ HPV vaccination
knowledge and expertise, they viewed the time that it took to schedule an appointment, travel to
the office, and wait for the provider as a significant barrier to seeking information. The women
noted that they have to balance part-time jobs, familial duties, and other responsibilities with their
school demands, so going to a healthcare provider to acquire information about the HPV vaccine
is an inconvenience. Instead, the women reported that they would be more likely to wait to learn
more about the vaccine when they had another, more pressing, reason to make an appointment
with their healthcare provider.
Joseina: Because like if I actually had time I would go to the [campus] health center because I know
that they do all that stuff, but since I really don’t have time . . .
Maylin: Well, I have so much to do. I have a hard time getting a good appointment time and then
having to wait. So, I would probably not go until some serious [health issue] came up. I’d ask [about
the HPV vaccine] then.
DISCUSSION
Understanding women’s perceptions and knowledge about the HPV vaccine provides a starting
point from which we can identify their informational processes, according to SNT (Berkman,
2000; Simons-Morton et al., 2009; Vanslyke et al., 2008). These women’s initial self-reports
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HPV VACCINE HISPANIC COLLEGE WOMEN 129
of HPV and HPV vaccine knowledge indicated that 80.9% “disagreed,” “somewhat disagreed,”
or were “unsure” when asked if they understood exactly what the purpose of the HPV vaccine
is. These reports were supported in their interview responses. Even among women who had
received the HPV vaccine, low levels of HPV vaccine knowledge were reported. Only one of
the HPV vaccine recipients said she was very knowledgeable about the vaccine; the remaining
vaccinated women reported that they had low knowledge about what the vaccine did or how to
continue to protect themselves. Only when probed were the women able to report that the vaccine
prevented HPV and protected them against acquiring cervical cancer. But the majority of these
women admitted that they were guessing, or gave this information in the form of a question.
These findings support prior research that has shown that Hispanic women and women attending
college have low levels of knowledge about HPV and HPV vaccination despite the availability
of resources and information on campuses (D’Urso et al., 2007; Sandfort & Pleasant, 2009;
Vanslyke et al., 2008). The low level of knowledge found during our study illustrates that these
young Hispanic women’s current social networks provided inadequate levels of credible, reliable,
and accurate HPV vaccine information. Further, it provides a reference point from which SNT
can be used to assist in the identification of specific behavioral interventions for Hispanic college
women, as these young women gauge perceptions of their own risk and knowledge based on their
specific cultural social networks.
Social Networks Currently Providing HPV Vaccination Information
After reflecting on their current HPV vaccine knowledge and the social networks through which
they acquired this information, participants reported that television programming was the most
important source of information, followed by communication from their mothers.
Television
Clearly, television messaging did raise awareness about the HPV vaccine for these women. The
Gardasil commercials provided the most recognized television message about HPV vaccine, and
18 stated that they had seen it. Most of these participants specifically remembered the “One Less”
slogan, that it prevented cervical cancer, and that it involved getting a shot. However, no other
information from the commercial was retained. The women thought the commercial’s content
did not provide enough information to significantly influence their HPV vaccine decision-making
process.
Participants also reported that television news programming provided them with HPV in-
formation; however, they thought that the information they had received was inadequate. The
lack of adequate HPV information from television programming was also reported by Wallace
and Ache (2009), who examined the content of HPV-related vaccination information presented
during nightly national television news broadcasts in the United States. They found that 66.7%
of the coverage presented information pertaining to HPV and cervical cancer focused on infor-
mation about vaccine labeling, the impact of the vaccine, and concerns about the vaccine—not
information detailing the vaccine’s purpose or how to access the vaccine for personal use.
Despite the superficial content, it is important to consider the impact of HPV vaccination
messages via television programming over time. The HPV vaccine was approved for use in
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130 STEPHENS AND THOMAS
June 2006, and Merck started airing their Gardasil “One Less” commercials shortly afterward.
Similarly, HPV vaccination gained worldwide attention in both academic and popular culture
circles when Texas Governor Rick Perry’s attempt to require that girls in Texas be vaccinated
became a point of contention in the presidential primary election debates (Gann, 2011). Opponent
Michele Bachmann said he was “flat out wrong” to require that “innocent little 12-year-old girls
be forced to have a government injection through an executive order” and suggested it was “a
very dangerous drug” that could cause “mental retardation” (Gann, 2011). As the media continue
to cover news about the HPV vaccine, the impact of this social network’s messages on Hispanic
college women should increase, according to SNT. In fact, results from studies of the relationship
between exposure to television news messages about cervical cancer and women’s vulnerability
perceptions show that viewing multiple television reports significantly increased women’s fears
about getting HPV (Lemal & Van den Bulck, 2010; Wallace & Ache, 2009). For example, Lemal
and Van den Bulck (2010) found that women who had been occasionally exposed to cervical
cancer messages on television were twice as likely to be very afraid of getting cervical cancer as
those who had not seen the messages (Lemal & Van den Bulck, 2010). Those frequently exposed
were three times more likely to be very afraid or extremely afraid and seven times more likely to
perceive a large risk of being diagnosed with cervical cancer (Lemal & Van den Bulck, 2010).
Increased levels of fear were associated with greater awareness and likelihood that women would
seek out more information about HPV vaccines.
Mothers
Another social network that participants maintained increased awareness about the HPV
vaccination was mothers. As asserted by SNT, mothers are proximal social networks and, thus,
play pivotal roles in healthcare decision-making processes because of their physical and emotional
closeness to their daughters. Further, researchers have noted that mothers often serve as a source
of inspiration and motivation for their daughters, even in conflictual relationships (Miranda, Bilot,
Peluso, Berman, & Van Meek, 2006; O’Sullivan, Meyer-Bahlburg, &Watkins, 2001).
Even when they found out about the vaccine from another source, the women would ask for or
follow their mothers’ advice about HPV and the HPV vaccine. In fact, over half of the women who
had had at least one HPV vaccine injection did so in part because of their mothers’ endorsements.
This supports prior research on sexual health that shows that Hispanic mothers’ messages about
HPV significantly influence adolescent women’s HPV vaccine uptake decision-making processes
(Sanderson et al., 2009). Researchers have found that mothers who support the HPV vaccine have
a direct influence on whether or not their adolescent and young adult daughters get vaccinated;
this is particularly true among those mothers who are routinely tested for HPV and among those
who have or have had HPV (Moraros et al., 2006; Perkins, Langrish, Cotton, & Simon, 2011). For
example, Sanderson et al. (2009) found that Hispanic mothers who were HPV-positive reported
that they would have their late adolescent daughters vaccinated even if they had to pay for the
vaccine themselves, and they were in favor of laws that require girls to receive the HPV vaccine
before entry into the sixth grade.
However, these mother-daughter conversations failed to communicate comprehensive infor-
mation about the HPV vaccine. The participants said that their mothers positively influenced their
decision-making processes, but their mothers did not provide information that increased their
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HPV VACCINE HISPANIC COLLEGE WOMEN 131
HPV vaccine knowledge. McRee, Reiter, Gottlieb, and Brewer (2011) also found that mothers
primarily discuss the benefits of the HPV vaccine as protection against cervical cancer, but are
less likely to share their beliefs about the perceived disadvantages of, or provide details about, the
HPV vaccine. The women in the current study similarly explained that their mothers told them
it was “okay” to get or that they have to get it because their mothers felt strongly about it. None
had conversations with their mothers that outlined facts about the vaccine, including its purpose,
potential risks/outcomes, or health implications. These results perhaps reflect mothers’ lack of
knowledge about the HPV vaccine rather than their decision to provide selective information.
Studies have shown that HPV knowledge among Hispanic women in general (Scarinci et al.,
2009; Watts et al., 2009), and among Hispanic mothers specifically (Moraros et al., 2006;
Sanderson et al., 2009), is typically low. Clearly, future efforts to address HPV vaccination
uptake by Hispanic college women must seek to increase the knowledge and validate the roles of
mothers in providing health information to their daughters. This new knowledge could, in turn,
influence Hispanic mothers’ endorsements, according to prior research (Moraros et al., 2006;
Perkins et al., 2011)
Preferred Social Networks for HPV Vaccination
The participants’ preferred social networks included the Internet, family members, and healthcare
providers (see Table 2). SNT’s selection processes pointed to several reasons why these networks
were selected and why in this particular order.
Internet
The primary reasons that these women choose to use the Internet were the desire to maintain
confidentiality while seeking sexual-health-related information and the convenience of quick
access. Studies have shown that emerging adults often turn to the Internet before consulting other
sources—including health professionals—because they can easily access it in their daily lives
(Boyar, Levine, & Zensius, 2011; Eysenbach, 2008; Rideout, 2001). Today’s college students
have immediate access to new media technologies through laptops, campus computer labs, cell
phones, and other devices. Given their constant access to the Internet, it is not surprising that more
than 70% of late adolescents and emerging adults report using it to source health information
(Boyar et al., 2011; Hansen, Derry, Resnick, & Richardson 2003). Further, the fact that the
Internet provided these women a degree of privacy and confidentiality when searching for HPV
vaccination information supports prior research that has shown that the nature of the topic
influences whether health information is sought on the Internet. Media psychology researchers
have asserted that many people, including young adults, are more likely to use the Internet
when seeking information about sensitive or potentially embarrassing health topics that are not
perceived as “severe diseases,” such as HPV and HPV vaccination uptake (Boyar et al., 2011;
Eysenbach, 2008; Rideout, 2001; Skinner, Biscope, Poland, & Goldberg, 2003).
That these women would use search engines over commercial health portals, such as Gardasil’s
website, and noncommercial, government-sponsored health portals, such as the CDC or Planned
Parenthood, corroborates prior research findings. Researchers have found that, when emerging
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132 STEPHENS AND THOMAS
adults have specific health problems or questions, they commonly enter a health-related search
term directly into a search engine (Eysenbach & Kohler, 2002; Hansen et al., 2003; Rideout,
2001). In a study that traced Internet health searches by adolescents, Hansen and colleagues
(2003) found that the majority of sites that students attempted to access were retrieved directly
from search engine results (77%) or the links recommended by a search engine (10%). This is an
issue of concern, because search engines often send consumers directly to a particular webpage
on a site, bypassing the home page, thereby making it difficult to discern who is behind a certain
webpage and what the authors’ motives and qualifications are (Eysenbach, 2008; Eysenbach
& Kohler, 2002). Further, Internet-based information often provides no verification of validity
of the information presented. This suggests that there is an urgent need for HPV researchers
and educators to check public-oriented healthcare information on the Internet for accuracy,
completeness, and consistency, because the sites of pharmaceutical companies are developed to
sell a product, whereas CDC sites are filled with public health information for the layperson as
well as the healthcare provider.
Family Members
The women in this study also reported that they would seek HPV vaccination information from
their family members, which supports prior researchers’ assertions that the role and influence
of family members must be prioritized when addressing the health knowledge concerns of
Hispanic college women (Miranda et al., 2006; Santiago-Rivera, Arredondo, & Gallardo-Cooper,
2002). The participants believed that family members are deeply invested in their health and
thought that family members would ensure that they received information that would improve
their health. Being that family members are proximal social networks, it is understandable that
familial messages about HPV vaccine directly affect the health decision-making processes of
Hispanic college women. Familial closeness, according to SNT, would provide Hispanic college
women information about appropriate familial and cultural norms with regard to health behaviors,
including HPV vaccination. Further, this closeness and investment in their health increases the
level of credibility Hispanic college women give to familial HPV vaccine messages, a central
construct in SNT (Berkman & Glass, 2002).
However, efforts to integrate HPV vaccine uptake information and values of family members
should be done with caution. The women interviewed expressed concern about whom in their
family they would turn to for information about the HPV vaccine. The construct of selection
in SNT explains that this is tied to the ways individuals embrace and share information about
health beliefs. For example, in the present study, HPV’s association with sexual intercourse
raised concerns about how vaccination might challenge familial and cultural gendered sexuality
norms. Specifically, discussions with family members about HPV vaccination focused on cervical
cancer risk and not sexual-health concerns, which could reflect a concern about the perception
that approval of HPV vaccination means approval of sexual intercourse. Traditional Hispanic
values about female sexuality stress conservative gender-role beliefs, including the celebration
of virginity and denouncement of premarital sex (O’Sullivan et al., 2001; Raffaelli & Ontai,
2001). Tied to this is a trend to delay discussions about sexuality issues with daughters until
they are married (O’Sullivan et al., 2001; Raffaelli & Ontai, 2001). Thus, it could be inferred
that both parents and daughters are reluctant to share general and detailed information about
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HPV VACCINE HISPANIC COLLEGE WOMEN 133
sexuality-related issues with each other, including the HPV vaccine (Berkman, 2000; Berkman
& Glass, 2002; Simons-Morton et al., 2009).
Further, as 23 of the women lived with their parents, there is potentially an additional pres-
sure for these women to maintain and follow familial expectations about their sexuality and
sexual health. However, it is important that those disseminating HPV vaccination information
allow college women to determine how much familial interference is appropriate. Despite the
physical and emotional closeness they have with their parents, some women might prefer not to
embrace traditional values and customs, particularly as they relate to sexual-health issues, such
as HPV. This is illustrative of the negotiation that, SNT argues, occurs between the selection and
socialization processes. There is the closeness and value given to parental messaging, but the
various generational and cultural sexuality values require careful consideration of the ways in
which social networks’ influence differs according to the context, individual experience, and the
particular sexual health issue.
Healthcare Providers
The women in this study also perceived healthcare providers as important future sources of
HPV vaccine information. As was found in prior research, healthcare providers, by virtue of their
skills, education, and training, were respected as health authority figures by these women, who
valued their health directives and services (Guendelman & Wagner, 2000; Hopfer & Clippard,
2011). The women in this study said that healthcare providers’ expertise and access to the most
up-to-date HPV vaccine information increased their trust in these professionals and their desire to
obtain more information during future visits. We cannot, however, ignore concerns that seeking
information from healthcare providers was often inconvenient. These women reported the time
it takes to book an appointment, travel to the office, and wait to see a doctor is a deterrent;
this supports prior research findings that those with higher valuation of time are more likely to
cancel appointments or seek alternatives, such as Internet information (Guendelman & Wagner,
2000). Unfortunately, this research has traditionally focused on men, working adults, and those in
hospital settings, whose situations differ greatly from those of college women. Thus, this finding
introduces an important area of focus for future research on this population’s health-seeking
behaviors. Integrating an SNT approach would allow for the identification of the ways in which
healthcare providers, as a social network, can strengthen their influence on Hispanic women’s
positive health outcomes. Further, it will help researchers to understand what barriers exist
(e.g., inconvenience, time constraints) in the development of a strong relationship between these
two network members.
This kind of information is particularly important to Hispanic college populations. Although
researchers have also frequently reported that Hispanics are less likely than other ethnic groups
to seek and receive healthcare services (Guendelman & Wagner, 2000; Miranda et al., 2006), we
suggest that those attitudes are not applicable to this specific population. As registered students,
these women have access to a campus-based health facility that includes full-time physicians,
a fully staffed women’s clinic, sexual-health services, and psychological services. In addition,
the institution requires all students to purchase a subsidized health insurance plan; students can
opt out only if they have other health insurance coverage. Thus, efforts to address the healthcare
needs of Hispanic women attending college must take into consideration their unique contextual
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134 STEPHENS AND THOMAS
experiences. Further research on the socialization, selection, and social norm processes is clearly
needed if the goal is to develop culturally appropriate HPV vaccine education and implementation
tools for healthcare providers to share with this population (Hopfer & Clippard, 2011).
The narratives of these women underscore the importance of ensuring that healthcare providers
are firmly integrated into Hispanic college women’s HPV vaccination information efforts. Women
who are immunized with Gardasil still require yearly Pap smears, because the vaccine does not
protect against all HPV strains associated with cervical cancer, nor does it protect against other
causes, including genetic defects and exposure to carcinogenic compounds in cigarette smoke
(Munoz et al., 2010). Clearly, it would be foolish to completely overlook healthcare providers as
important social networks players, even when research—including the present study—shows that
other sources appear to be more influential in shaping HPV vaccination uptake decision-making
processes of Hispanic college women.
The Internet, family members, and healthcare providers should be approached as comple-
mentary sources of HPV vaccination information for Hispanic college women. Although the
participants’ responses ranked them in order of preference, the rankings were based on percep-
tions of convenience (e.g., lack of time for other options, ease of access, accessibility privacy),
trust (i.e., sense of personal investment in their health), and expertise (i.e., knowledge and train-
ing), rather than the source itself or mode of communication. For example, when asked if their
primary healthcare provider encouraged them to get the HPV vaccine, the majority of the women
said that they would consider vaccination after both seeking further information online and ob-
taining feedback from family. Researchers must recognize the importance of this knowledge,
because Hispanic college women’s perceptions of their social connectedness to and means of
communication with these social networks will have significant positive association with their
health status (Berkman, 2000; Hopfer & Clippard, 2011; Simons-Morton et al., 2009; Vanslyke
et al., 2008).
Limitations
The present study, as any study, has limitations that should be addressed. This was a small,
nonrandom group of women attending a Hispanic-serving institution in an urban center that is
greater than 70% Hispanic. The majority of the participants had resided in the United States for
the majority of their lives, and they self-identified as White-Hispanic and heterosexual. Thus,
there was little intracultural variation in acculturation/immigration experiences, racial identity,
sexual orientation, community of residence composition, and socioeconomic status. This study
also required participants to report levels of knowledge and relate personal experiences tied to
sexual health. When they were sitting in front of the interviewers, participants might have chosen
to limit the truthfulness of their responses or to omit relevant information. Further, close attention
must be paid to the influence of university resources’ accessibility. All of the women in the
present study had access to a variety of campus-based health services with the capacity to provide
HPV-related services and education. Similarly, online informational tools, including computer
labs and Internet service, are readily available at no additional cost to students. Whether women
attending postsecondary institutions with fewer health or technology resources would have the
same perceptions about HPV vaccination sources of information is an important issue to explore
in future studies.
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HPV VACCINE HISPANIC COLLEGE WOMEN 135
CONCLUSION
Although we recognize these limitations, our findings represent an important addition to what
is currently a small body of research about the engagement by Hispanic college women in
identifiable and distinctive health-information social networks. Specifically, Internet resources,
family members, and healthcare providers play significant roles in providing health information
that influenced these women’s decision-making processes. Given that over one third of the
women in the study had not yet become sexually active, it is clear that there is still a need to target
this population’s specific HPV vaccination uptake information processes to identify their HPV
and HPV vaccine concerns. This is particularly urgent as rates of HPV-related cervical cancers
continue to remain high among Hispanic women. Future research on the specific influences of
the Internet, familial units, and healthcare providers could provide additional insights into the
importance of validating and identifying Hispanic women’s sexual health concerns, the influence
of social networks, and ways to improve the quality of the information they receive from those
networks.
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