Barriers to and facilitators of human papillomavirus vaccination in an ethnically diverse group of migrant parents: A qualitative mixed methods study

Figures & data

Figure 1. A. Khan’s framework: access to care and prevention.

Table 1. Sociodemographic information of Interview participants.

Characteristics	Respondents (N = 15)	%
Survey Language
English	15	100
Gender
Female	10	66.7
Male	5	33.3
Immigrant & Refugee Group
Very recent Immigrants (landed immigrants who had been in Canada for five years or less)	9	60.0
Recent Immigrants (landed immigrants for more than 5 to 10 years in Canada)	3	20.0
Established Immigrants (landed immigrants for more than 10 years)	2	13.3
Refugee (landed as a refugee)	1	6.7
Racial Or Ethnic Identity
Black	6	40.0
Chinese	1	6.7
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)	6	40.0
Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.)	2	13.3
Number of children between the ages of 9–17 (or are in grade 6 or higher)?
1–2	9	60
2–3	4	26.7
3–4	2	13.3
Gender of Children
Male child(ren)	2	13.3
Female child(ren)	7	46.7
Both Male and Female child(ren)	6	40.0
Level of Education
Primary/Elementary School	1	6.7
Middle School	2	13.3
Secondary School/High School	0	0
Postsecondary/Tertiary Education	12	80.0
Able To Save Some Money After Family Expenditures At The End Of The Month?
Yes	8	53.3
No	7	46.7
Respondent’s HPV vaccine status
Yes	4	26.7
No	11	73.3

Table 2. Focus group participant survey responses: socio-demographic characteristics.

Total Migrant (immigrants & refugees) Participants (N = 16)	Black (n = 6)	South Asian and Southeast Asians (n = 5)	West Asian (n = 5)	Cumulative Responses (N = 16)
Gender	Females (n = 0) Males (n = 6)	Females (n = 4) Males (n = 1)	Females (n = 4) Males (n = 1)	Females (N = 8) Males (N = 8)
Age range	20–30 (n = 0) 30–40 (n = 0) 40–50 (n = 6) 50–60 (n = 0)	20–30 (n = 1) 30–40 (n = 2) 40–50 (n = 2) 50–60 (n = 0)	20–30 (n = 1) 30–40 (n = 1) 40–50 (n = 1) 50–60 (n = 2)	20–30 (N = 2) 30–40 (N = 3) 40–50 (N = 9) 50–60 (N = 2)
Parental Status	Guardian (n = 0) Mother (n = 0) Father (n = 6)	Guardian (n = 0) Mother (n = 4) Father (n = 1)	Guardian (n = 1) Mother (n = 3) Father (n = 1)	Guardian (N = 1) Mother (N = 7) Father (N = 8)
Migration status	Immigrant (n = 6)	Immigrant (n = 5)	Refugee (n = 5)	Immigrants (N = 11) Refugee (N = 5)
Racial or Ethnic Identity	Black (n = 6)	South Asian (n = 4) Southeast Asian (n = 1)	West Asian (n = 5)	Black (N = 6) Asian (N = 10)
Duration of Stay in Canada	6 months (n = 2) 2 years (n = 1) 3 years (n = 1) Unsure (n = 2)	9 months (n = 1) 10 years (n = 1) 17 years (n = 1) 16 years (n = 1) 12 years (n = 1) Unsure (n = 0)	5 months (n = 3) 4 months (n = 1) 6 months (n = 1) Unsure (n = 0)	Immigrants (Range: 6 months −17 years) Refugees (Range: 4–6 months)

*Where total (N) does not sum to the individual numbers, it means the respondent has skipped the question (& chose not to answer).

+Because participants under this group were all very recent to recent migrants (refugee category).

*Definition of Migrants, Immigrants and Refugee: They are often used interchangeably, which is inaccurate. Migrants and immigrants have a few factors in common, but they are two separate groups (Gogol 2020).

*The migrant is a broad term that applies to an individual who willingly leaves home and moves from one place to another, mostly searching for employment, and his/her movement is temporary. Thus migrant people include those who move from one region to another within the borders of their own country OR move from their country of birth to another country or countries (Love) 2019).

*Migrants can include refugees, but refugees do not always include migrants. A migrant is one who purposefully moves in search of a better life but can return home at any time if they choose to.

*Immigrants are migrants who willingly leave their country of origin and legally enter another country where they have permission to permanently resettle, thus qualifying them to work without any restrictions. Immigrants’ reasons for relocation and resettlement can be many, from economic prosperity to better education to the fulfillment of a dream or reunion with family or beyond.

Table 3. Focus group participant survey responses: knowledge about HPV infection and experience with HPV school-based immunization program.

Total Migrant (immigrants and refugees) Participants (N = 16)	Black (n = 6)	South Asian and Southeast Asians (n = 5)	West Asian (n = 5)	Cumulative Responses (N = 16)
Do you have experience with school-based HPV immunization programs?	Yes (n = 5)	Yes (n = 5)	Yes (n = 1)	Yes (N = 10)
	No (n = 1)	No (n = 0)	No (n = 5)	No (N = 6)
Do you think HPV infections are sexually transmitted?	Yes (n = 3)	Yes (n = 4)	Yes (n = 2)	Yes (N = 9)
	No (n = 1)	No (n = 0)	No (n = 0)	No (N = 1)
	Do not know (n = 0)	Do not know (n = 0)	Do not know (n = 2)	Do not know (N = 2)
	Unsure (n = 2)	Unsure (n = 1)	Unsure (n = 1)	Unsure (N = 4)
Do you know HPV infection can cause cancer of the cervix, throat, anus, and male and female genitalia?	Yes (n = 3)	Yes (n = 5)	Yes (n = 1)	Yes (N = 9)
	No (n = 0)	No (n = 0)	No (n = 1)	No (N = 1)
	Do not know (n = 0)	Do not know (n = 0)	Do not know (n = 1)	Do not know (N = 1)
	Unsure (n = 3)	Unsure (n = 0)	Unsure (n = 2)	Unsure (N = 5)
What, in your opinion, is the best way to educate people about HPV infection and HPV vaccines?	Social Media (n = 6)	Social Media (n = 3)	Social Media (n = 2)	Social Media (N = 11)
	Interactions: educational sessions, workshops, meetings, physicians’ appointment (n = 0)	Interactions: educational sessions, workshops, meetings, physicians’ appointment (n = 2)	Interactions: educational sessions, workshops, meetings (n = 2)	Interactions: educational sessions, workshops, meetings (N = 4)
	No response (n = 0)	No response (n = 0)	No response (n = 1)	No response (N = 1)
What is your preferred way of receiving the consent form and vaccine information sheet from the school?	Email (n = 4)	Email (n = 1)	Email (n = 3)	Email (N = 8)
	Paper copies (n = 0)	Paper copies (n = 1)	Paper copies (n = 0)	Paper copies (N = 1)
	Email & Paper copy (n = 1)	Email & Paper copy (n = 3)	Email & Paper copy (n = 2)	Email & Paper copy (N = 6)
	School App: Edsby (n = 1)	School App: Edsby (n = 0)	School App: Edsby (n = 0)	School App: Edsby (N = 1)
How comfortable are you reading and understanding the consent form and vaccine information sheet provided to you by the school?	Very comfortable (n = 5)	Very comfortable (n = 4)	Very comfortable (n = 2)	Very comfortable (N = 11)
	Somewhat comfortable (n = 0)	Somewhat comfortable (n = 1)	Somewhat comfortable (n = 3)	Somewhat comfortable (N = 4)
	Not comfortable (n = 1)	Not comfortable (n = 0)	Not comfortable (n = 0)	Not comfortable (N = 1)
Do you know that vaccine information sheets are also available in languages other than English?	Yes, I am aware (n = 4)	Yes, I am aware (n = 2)	Yes, I am aware (n = 1)	Yes, I am aware (N = 7)
	No, I am not aware (n = 2)	No, I am not aware (n = 3)	No, I am not aware (n = 4)	No, I am not aware (N = 9)
Have you had sufficient time to review immunization materials (i.e., information page, consent form) before the HPV vaccine clinic at your child’s school?	Yes (n = 3)	Yes (n = 2)	Yes (n = 1)	Yes (N = 6)
	No (n = 3)	No (n = 3)	No (n = 4)	No (N = 10)
Do you prefer school-based vaccine programs?	Yes (n = 4)	Yes (n = 4)	Yes (n = 2)	Yes (N = 10)
	No (n = 2)	No (n = 1)	No (n = 3)	No (N = 6)
Were you comfortable with the school HPV vaccine clinic timing?	Yes (n = 5)	Yes (n = 3)	Yes (n = 2)	Yes (N = 10)
	No (n = 1)	No (n = 2)	No (n = 3)	No (N = 6)
I have access to all of the information I need to make good decisions about immunizing my child with the HPV vaccine	Agree (n = 1)	Agree (n = 3)	Agree (n = 0)	Agree (N = 4)
	Disagree (n = 0)	Disagree (n = 1)	Disagree (n = 2)	Disagree (N = 3)
	Strongly disagree (n = 3)	Strongly disagree (n = 1)	Strongly disagree (n = 1)	Strongly disagree (N = 5)
	Neither agree nor disagree (n = 2)	Neither agree nor disagree (n = 0)	Neither agree nor disagree (n = 2)	Neither agree nor disagree (N = 4)
How comfortable were you in arranging previous vaccine records of your child(ren) from a previous country or province?	Very comfortable (n = 3)	Very comfortable (n = 1)	Very comfortable (n = 1)	Very comfortable (N = 5)
	Somewhat comfortable (n = 1)	Somewhat comfortable (n = 3)	Somewhat comfortable (n = 2)	Somewhat comfortable (N = 6)
	Not comfortable (n = 1)	Not comfortable (n = 1)	Not comfortable (n = 1)	Not comfortable (N = 3)
	Not applicable (n = 1)	Not applicable (n = 0)	Not applicable (n = 1)	Not applicable (N = 2)
Do you think arranging a vaccine record of your kid from a previous country or province impacted your decision to consent to the HPV vaccine?	Yes (n = 1)	Yes (n = 3)	Yes (n = 1)	Yes (N = 5)
	No (n = 4)	No (n = 1)	No (n = 3)	No (N = 8)
	Not applicable (n = 1)	Not applicable (n = 1)	Not applicable (n = 1)	Not applicable (N = 3)
Has the COVID Vaccine experience changed your attitude toward vaccines?	Yes (n = 4)	Yes (n = 2)	Yes (n = 1)	Yes (N = 7)
	No (n = 2)	No (n = 1)	No (n = 3)	No (N = 6)
	Unsure (n = 0)	Unsure (n = 2)	Unsure (n = 1)	Unsure (N = 3)
How has the COVID vaccine experience changed your attitude toward vaccines?	Increased the likelihood of getting other vaccines (n = 4)	Increased the likelihood of getting other vaccines (n = 2)	Increased the likelihood of getting other vaccines (n = 3)	Increased the likelihood of getting other vaccines (N = 9)
	Decreased the likelihood of getting other vaccines (n = 0)	Decreased the likelihood of getting other vaccines (n = 2)	Decreased the likelihood of getting other vaccines (n = 0)	Decreased the likelihood of getting other vaccines (N = 2)
	Unchanged (n = 1)	Unchanged (n = 1)	Unchanged (n = 2)	Unchanged (N = 4)

*Where total (N) does not sum to the individual numbers, it means the respondent has skipped the question (& chose not to answer).

+Because participants under this group were all very recent to recent migrants (refugee category).

*Definition of Migrants, Immigrants and Refugee: They are often used interchangeably, which is inaccurate. Migrants and immigrants have a few factors in common, but they are two separate groups (Gogol 2020).

*The migrant is a broad term that applies to an individual who willingly leaves home and moves from one place to another, mostly searching for employment, and his/her movement is temporary. Thus migrant people include those who move from one region to another within the borders of their own country OR move from their country of birth to another country or countries (Love) 2019).

*Migrants can include refugees, but refugees do not always include migrants. A migrant is one who purposefully moves in search of a better life but can return home at any time if they choose to.

*Immigrants are migrants who willingly leave their country of origin and legally enter another country where they have permission to permanently resettle, thus qualifying them to work without any restrictions. Immigrants’ reasons for relocation and resettlement can be many, from economic prosperity to better education to the fulfilment of a dream or reunion with family or beyond.

Table 4. Migrant Parents’ perception of barriers to and facilitators of HPV vaccination in interviews and FGD: key themes and exemplar quote.

A. Khan’s Framework (Bio-Psycho- Social Determinants)	A. Khan’s Framework Patient Level Determinants of HPVV Uptake	Main Themes	Sub-Them OR Subgroups	Factor (Barrier OR Facilitator)	Exemplar Quote
Psyco-Social	Ability to Perceive & Engage	Information, Awareness & Education	Exchange Of Information Between the Three: Parents, School, And Kids	Facilitator	“Just to be more informative. The parents who don’t have any idea like me. Of course, I will do research and stuff like that. Just came out somewhere that doesn’t have any idea what that is. They will be like, “Oh, they’re putting the needles on our children.” What type of needles are they? What types of vaccines are there? Children also need to know why they are having. They need some sort of education. There should be a good flow of information and exchange of information between the three. Parents, school, and kids as well because the kid is the one getting shot.” (Black Immigrant Parent, Interview#10).
			Parental Unawareness	Barrier	“I don’t know about it. I’m just listening to this, and I don’t know why my children had the vaccination. I’ve heard about vaccinations; it’s there not to have further problems in life and stopping from further problems. Because just thinking about cancer, right? When the word cancer comes up, you think you cannot usually cure or prevent it. That’s why the idea is stuck in my head.” (Chinese Immigrant Parent, Interview#7)
			Parental uncertainty about HPV vaccine safety and necessity	Barrier	“We need to get more awareness about the HPV vaccine through schools because when my kids were younger, 10–15 years ago, at that time, I was not sure about it. I didn’t think that it would be a nice idea for my kids they need a vaccination for that because I was not aware of it; I was not sure about it; what is this? The other thing was that they were not sexually active, so why did they need it? It was like, maybe this vaccine is safe for them or not? That was another question for me. I didn’t think it was necessary for them & for me to think it is important for them.” (Black Immigrant Parent, Interview#3)
			Prevention is Better than Cure	Facilitator	“I believe in prevention is better than cure logic. So, if you can get a vaccine that can help us from HPV infection and is also effective afterwards and get them to our kids, to a younger age group – it is good. I want to put myself in the spot and say that I did not get an HPV until I moved to Canada. I came from a different country and did not have the HPV vaccine until I moved here. So, I wish I had gotten it when I was younger, just to be on the safe side. Just to not be exposed to the virus at all. So, I believe that it’s better to get them before the infection or the virus.” (Black Immigrant Parents, FGD-3)
			HPVV campaign following COVID as an example	Facilitator	“Parents naturally respond fairly to anything that has to do with the kids. As people have already said, we should try a campaign. There should be a serious campaign about HPV. Because most people like me, honestly, I heard about it last year when we had individual interviews. The point is that the HPV vaccine needs more promotion. They need to make people more aware that it should become something everybody knows about. Like, COVID. Nobody we see doesn’t know; even small kids would tell you what COVID-19 is and what the vaccine is. There should be more sensitizations, and people through the school program should be promoted through different mediums.”(Black Immigrant Parent, FGD-3)
			Misconception: Gender Association with HPVV	Barrier	“I just wanted to mention that, for the first time, I’m learning that boys could also be affected because I have always thought this was for the girl child. So, for the first time, I’m learning that boys could be affected, and I think this is an opportunity for me to go and read up more on what this is all about.” (Black Immigrant Parent, Interview #13)
	Ability to Seek	Vaccine- Related Logistics	Vaccine Info Sheet too Technical or Wordy: Not a user-friendly guide	Barrier	“I went back to how it should be done, how it wasn’t done, and how we should’ve done it. Here, they’re sending an immunization sheet informing the parents. I say yes or no. That is consent which is fine. The kid’s parents say no, I’m gonna say no. They’re not gonna force the needles in for the kids. Since they know, you want to explain what kind of vaccination they’re taking and what it is for because sometimes you’re just putting the abbreviations and names of that stuff. Nobody knows what their use is. You put out the brief of what this one is, what it prevents, if it has any side effects, and stuff like that. So, a layperson can understand that by just going through that. Also, it must be brief so that nobody can read two pages of such material.” (Black immigrant parent, Interview#11)
			Vaccine Info Sheet In a Different Language	Facilitator	“The kind of information I would like to see is that the information sheet should be made available to everybody in different languages because some people actually don’t really read the sheet; I know people don’t read English. If we could have multilingual information sheets for families that are not English based, that would make lots of sense. Also, there are some basic languages that we have; we know Mandarin, and we know Arabic. We know that a few languages are predominant – they are dominating Saskatchewan quite a bit. And so, seeing those basic pamphlets online, that would be great if we could click it and it opens in my language. I would love that.”(South Asian Immigrant Parents, FGD-1)
			Elaborate on the word “sexual” on the information sheet about the HPV vaccine	Facilitator	Of course, the information sheets is something that, if I don’t understand clearly, I’m not going to mark a check on the consent form. If I’m not understanding what HPV means because it’s confusing to me, I will, just to be on safe side, I won’t put a check mark next to the consent form. Also, if you put a word “sexual” in front on the sheet, it kind of becomes a big taboo. And without understanding it, people will not consent to it because there’s the word “sexual” on there. So, it can be sexually transmitted disease. Just like the other participant said, my kid is not sexually active, so they’re not going to get it. We don’t think about the future, we are just thinking about right now and that can be a really big thing, especially for some cultures. So, explain clearly”(Black Immigrant Parents, FGD-3)
Environmental/ Contextual	Ability to Reach		Hybrid Approach (Paper+ Electronic): Distribution of Vaccine Info Packages: Child as a medium of vaccine package delivery	Barrier	“The only thing I can think of right now is they send their forms with children, and children are supposed to go and hand them back. If a child is not careful enough or has not grown up yet to that stage, they may misplace the form, forget to give it, or not reach back to the nurse. The form might never come to the parents, so parents may never know that the vaccine is taking place and may miss it. The nurse will think that they didn’t give consent. Public schools are going paperless in many things. They have platforms like Edsby, and the different ways teachers communicate with us directly on those platforms give us the performance and day-to-day things. They have our emails. They also send us emails. Yes, they can send forms directly to us and get our consent directly from us. It will be quicker than no chance of getting it misplaced by the child.” (Black Refugee Parent, Interview#2)
			Clear Messaging on Vaccine Info Sheet	Facilitator	“I just heard what the other participant had said. You want to have information that can easily be on what I call it a level one. Which is something that people can just read clear English, in clear terms. Why are we taking this stuff? What’s it preventing? What’s the use for this and how it’s going to help? If people don’t have clear information, it doesn’t really give so much of confidence of why if it’s a necessity to have such a vaccine. If you have a clear information stating exactly what is required or what the vaccine will do then yes, that would be a good one”(West Asian Refugee Parents, FGD-2)
	Ability to Seek		Lack of Physicians’ Recommendation	Barrier	“Honestly, people around me or in my community and my family physician did not talk to me about this vaccination. I did not get any information. I feel like since it’s so important- we talk so much about other vaccines, like we place so much importance on polio and all of those vaccines. We also eradicated them, and that only came about by spreading so much information. I feel like there wasn’t much information about HPV.” (South Asian Immigrant Parent, Interview#8)
			Catch-Up vaccine day for a missed opportunity	Facilitator	“I think that’s a great idea if we can get a catch-up HPV vaccine clinic for those kids who couldn’t get it when offered for the first time because sometimes kids are away from school at the time. They are sick or they are on vacation, so it’s a great idea if we can get a vaccine clinic twice a year or again two times. That would be great.”(West Asian Refugee Parents, FGD-2)

+A certain factor could be counted as a barrier or a facilitator. This is because if a certain factor is considered a barrier, addressing it would facilitate the process of HPV vaccine administration/uptake; therefore, we can also consider it a potential facilitator. In this table, we labelled factors as ‘facilitators’ where the participants suggested potential solutions to increase the uptake of HPVV.

+Facilitators highlighted in this table are mostly suggested/potential facilitators.

+Based on A. Khan’s Framework for Access to Care and Prevention, the Patient-level (Demand side) determinants of HPVV uptake include the Ability to Engage, Ability to Pay, Ability to Reach, Ability to Seek, and Ability to Perceive. In the table above, the if any theme is missing then it means it did not appear, which implies that it did not emerge as a factor in the HPVV uptake for the patient-level participants’ data.