Vaccine-related attitudes and decision-making among uninsured, Latin American immigrant mothers of adolescent daughters: a qualitative study

ABSTRACT

Uninsured Latin American immigrant women are at increased risk for vaccine preventable diseases, such as cervical cancer; yet gaps in vaccine coverage persist. The purpose of this study was to explore vaccine-related knowledge, attitudes and decision-making for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, meningococcal conjugate vaccine (MenACWY), and human papillomavirus (HPV) vaccine among uninsured Latin American immigrant mothers of adolescent daughters. A purposive sample of 30 low-income, uninsured, predominantly Latin-American immigrant mothers of adolescent daughters aged 13–17 were recruited from two academic-community managed health clinics in Virginia. From March–September 2016, data were collected through in-person, semi-structured interviews, in English or Spanish. For data analysis, conventional content analysis was employed. The majority of participants self-identified as Hispanic and had less than a high-school level education. Key themes included: general acceptance of vaccines; associating vaccines with prevention/protection; minimal vaccine hesitancy; and lack of knowledge regarding vaccine-preventable diseases, vaccines recommended for adolescents, and adolescent daughters’ vaccination history. Doctors’ recommendation, school requirements, and the media were key influencers of vaccination. Mothers were the primary decision-maker regarding vaccine uptake among their adolescent daughters. Findings highlight the need for efforts to help uninsured Latin American immigrant mothers better understand vaccines, and provide linkages to affordable, accessible vaccines among under-resourced populations.

KEYWORDS:

• Vaccine
• HPV
• attitudes
• behavior
• qualitative

Introduction

Adolescents are at risk for multiple vaccine-preventable diseases, including pertussis, meningococcal disease, and human papillomavirus (HPV)–associated cancers.^1–4 Each of these diseases is serious, with the potential to cause severe adverse health outcomes. Pertussis is a highly contagious respiratory infection, characterized by paroxysms, paroxysm-related vomiting, and exhaustion; severe consequences include acute encephalopathy, seizures, or pneumonia.^5,6 In 2016, over 17,000 cases of pertussis were reported to the Centers for Disease Control and Prevention (CDC), with 34% of cases occurring among adolescents.⁷ Meningococcal disease is spread through person-to-person transmission, and commonly causes meningococcal meningitis, pneumonia, and meningococcal septicemia; severe cases may result in death, which can occur quickly.^8,9 In 2016, about 370 cases of meningococcal disease were reported in the United States.⁹ Although the incidence of vaccine-preventable serogroups are at historic lows, a peak in adolescents and young adults persists.⁹ HPV is a sexually transmitted infection, spread through skin-to-skin contact.¹⁰ Over half of adolescents have had sex by age 18,¹¹ placing them at risk for HPV infection. HPV causes genital warts, nearly all cervical cancers, and many vulvar, vaginal, penile, anal, and oropharyngeal cancers.¹² From 2010–2014, approximately 41,000 HPV-associated cancers were diagnosed annually in the United States.¹³ Few HPV-associated cancers are actually diagnosed among adolescents; the median age of diagnosis ranges from 49 for cervical cancer to 68 for penile cancer.¹⁴ However, HPV-associated cancers can take between 10 and 30 years to occur after initial infection with HPV.¹⁵ Thus, prevention during adolescence is critical.

Research has shown that vaccination is an effective method to reduce the morbidity, mortality, and economic costs associated with these diseases among adolescents.^16–18 Vaccination against pertussis can prevent infection and reduce illness severity, duration, and transmission.¹⁹ Vaccination against meningococcal disease can prevent infection caused by predominant serotypes in the United States.² Vaccination against HPV can prevent infection caused by up to 9 types of HPV, including HPV 16 and 18, which are most commonly associated with invasive HPV-associated cancers.⁴ The CDC’s Advisory Committee on Immunization Practices (ACIP) recommends routine immunization for adolescents aged 11–12 years for protection against each of these diseases: tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, meningococcal conjugate vaccine (MenACWY), and human papillomavirus (HPV) vaccine;^20,21 catch-up vaccination is recommended for adolescents aged 13–18 years who have been previously missed.

Despite the ACIP’s recommendation, vaccination coverage rates among adolescents are sub-optimal, especially for HPV vaccine.²² Furthermore, throughout the Commonwealth of Virginia, coverage rates for adolescent vaccines falls below the national average.²² In 2016, 87% of adolescents aged 13–17 years received ≥ 1 Tdap vaccine, and only 72% of adolescents received ≥ 1 MenACWY vaccine, more than 10% below the national average.²² HPV vaccine uptake was particularly low; only 51% of female adolescents aged 13–17 years received ≥ 1 HPV vaccine dose – 15% lower than the national average – and only 41% were up-to-date.

In 2014, Virginia had the 15th largest Hispanic population in the United States²³ – a group that faces an increased risk for vaccine-preventable diseases, such as cervical cancer.²⁴ While national data indicate that adolescents of Hispanic origin are substantially more likely than White, non-Hispanic adolescents to receive the MenACWY vaccine and the full HPV vaccine series,²⁵ vaccine coverage among Hispanic adolescents in Virginia falls below that of Hispanic adolescents nationally. In 2016, only 65.4% of Hispanic adolescents in Virginia received ≥ 1 Tdap vaccine, compared to a national average of 85.4%; 58.6% received ≥ 1 MenACWY vaccine, compared to a national average of 83.8%; and 65.0% received ≥ 1 HPV vaccine dose, compared to national average of 69.8%.^26–29

Structural-level factors (e.g., lack of health insurance, poverty, and immigration status) act as barriers to vaccination among Hispanic populations. Among the 732,000 persons identifying as Hispanic in Virginia, foreign-born Hispanics comprise of nearly half this figure (46%), the fourth highest in the United States.²³ Additionally, 27% of Hispanics in Virginia were uninsured in 2014: 45% among foreign-born Hispanics and 12% among U.S.-born Hispanics.²³ Confronting each of these barriers to vaccination, particularly among Latin American immigrant communities, is essential to reduce gaps in vaccine coverage.

In order to gain a comprehensive view into vaccine uptake among uninsured, Latin American adolescent females from immigrant families, it is important to explore the perspectives of their mothers, or primary female caregivers. Prior research has demonstrated the importance of both adolescent and parental attitudes with respect to vaccine acceptability.^30–32 The majority of previous studies exploring parental acceptability of adolescent vaccinations among Hispanic populations have focused exclusively on HPV vaccination. Lack of awareness and acculturation; concerns about sexuality, safety, and side effects; and low-perceived risk have been identified as barriers to HPV vaccine acceptability across Latino populations.³³ Fewer studies have examined decision-making for all recommended adolescent vaccines. One study conducted in Washington State found that lack of knowledge, misperceptions, lack of provider recommendations, and lack of access to health information in native language served as barriers to adolescent vaccination among diverse immigrant populations.³⁴ Another study conducted in Connecticut found that parents of adolescents from diverse ethnic backgrounds perceived the HPV vaccine to be similar to other routine vaccines.³⁵ However, additional research is needed to hone our understanding of vaccine-related knowledge, attitudes, and decision-making among uninsured, Latin American immigrant mothers of adolescent daughters – particularly in states with vaccination coverage rates below the national average, such as Virginia.

Identifying factors salient to uninsured, Latin American immigrant female caregivers of adolescent girls aged 11–17 regarding Tdap, meningococcal, and HPV vaccine decision-making is necessary to increase vaccination rates aligning with ACIP-recommended schedules in Virginia. The purpose of this study was to explore 1) overall attitudes toward vaccines; 2) knowledge and attitudes toward adolescent vaccines; and 3) vaccine decision-making among uninsured Latin American immigrant mothers of adolescent daughters seeking health services at two free health clinics in Northern Virginia.

Results

Demographics and health history

All participants were uninsured, which was a pre-requisite for receiving health services at the MAP clinics. In response to a brief set of closed ended questions regarding demographics and child’s health history, the majority of participants identified as Hispanic (26/30 = 86.7%), identified as “other” race (23/30 = 76.6%), primarily spoke Spanish at home (26/30 = 86.7%), had less than a high-school level education (17/30 = 56.7%), and were unemployed (18/30 = 60.0%) (Table 1). The average age among participants was 38.5 (SD = 9.1), and average number of children was 3.2 (SD = 1.3).

Table 1. Demographic and health history information among participants.

Variable	N (%) or Mean (SD)
Among mothers
Age	38.5 (9.1)
Identify as Hispanic
Yes	26 (86.7)
No	4 (13.3)
Race
White	6 (20.0)
Black	1 (3.3)
Other	23 (76.7)
Primary language spoken at home*
Spanish	26 (86.7)
Other	4 (13.3)
Level of education
Grades 8−11	17 (56.7)
High school or GED	5 (16.7)
Some college	4 (13.3)
College or higher	4 (13.3)
Employment
Unemployed	18 (60.0)
Work part time	5 (16.7)
Work full time	6 (20.0)
Student full time	1 (3.3)
Number of children	3.2 (1.3)
Among adolescent daughters
Age	14.8 (1.6)
Grade in school	8.7 (1.4)
Health insurance
None	23 (76.7)
Medicaid	5 (16.7)
Private	1 (3.3)
Missing	1 (3.3)
Received all childhood vaccines
Yes	24 (80.0)
No	5 (16.7)
Don’t know	1 (3.3)
Received flu vaccine in the past year
Yes	8 (26.7)
No	18 (60.0)
Don’t know	4 (13.3)

*Other included: Pashto (n = 1), Farsi (n = 1), English/Dutch (n = 1), English (n = 1)

Among participants’ adolescent daughters, the average age was 14.8 (SD = 1.6), and the average grade in school was 8.7 (1.4). The majority of adolescents had no health insurance (23/30 = 76.7%). According to participants, most adolescents were up-to-date on routine childhood vaccinations (e.g., MMR) (24/30 = 80.0%). When asked whether their adolescent child received a flu shot in the past year, most participants reported either no or don’t know (22/30 = 73.3%).

Qualitative results: major themes and illustrative quotes

Qualitative themes and illustrative quotes regarding vaccine decision-making are displayed in Table 2. Quotes are provided in English and Spanish, where relevant.

Table 2. Themes and illustrative quotes regarding vaccine decision-making for adolescent daughters among participants.

Major Themes	Illustrative quotes in English	Illustrative quotes in Spanish
Domain 1: Overall attitudes toward vaccines
General acceptance of vaccines	For children:
	“The word vaccine, how would I say umm, well, it should be necessary to vaccinate children”	“La palabra vacuna, que…como le dijera…hum…buen, que tiene que ser necesario vacunar los niños siempre.”
	“Mm, I could define it like something very important to our health. And besides, this vaccine helps the immune system and the body defenses and it is necessary, right? All of the ones that exist so our body can develop and have a good health system daily and forever, right?”	“ee yo podría este definirlo como que es algo importante verdad, para nuestra salud y aparte de eso pues la vacuna le ayuda a uno para el sistema inmunológico para las defesas, del cuerpo y que si es necesario verdad que hay una este todas las que existan pues estén en nuestro cuerpo para poderse desarrollar y poder tener un buen sistema de salud verdad uno a diario y para toda la vida verdad.”
	“Sometimes it’s scary, but we know it’s good, for the health of our children.”	“A veces da un poco de miedo, pero sabemos que es bueno para la salud de nuestros hijos.”
	For adolescents:
	“I feel the same because I know it’s good for her health”	“Me siento igual porque sé que es para su salud.”
	“Very good”	“Muy bien.”
	“The same… Yes, because it’s for their own good.”	“Lo mismo…Si, porque si es para bien de ellos.”
Prevention or protection	For children:
	“I think is, uh, some kind of protection to prevent different kinds of diseases”	Interview in English
	“Vaccine is something for the children, to protect them and I’ve always been in favor of the vaccines they took”	“Vacuna es un algo para los hijos que tiene uno que protegerlos a ellos y siempre he estado de acuerdo en sus vacunas.”
	“Illness prevention or shots for illness prevention”	Interview in English
	For adolescents:
	“Same, if it’s going to keep her healthy, then I’m all for it!”	Interview in English
	“I just wanted her to you know to be as healthy as possible and if this was the way to keep her healthy then that’s what I was willing to do.”	Interview in English
Mixed experiences with vaccines in the past	Positive experiences:
	“Well for the time being my kids never had a bad reaction to a vaccine”	“Pues, la realidad no ha tenido, por el momento no ha tenido ninguna reacción mala a los niños cuando he ido a poner vacunas.”
	“Well, no, everything was normal”	“Pues no, todo ha sido normal.”
	“Honestly, I don’t have a bad experience with a vaccine because all the time I receive the vaccines a good way”	Interview in English
	“No, I’ve never had and bad experiences… [my daughter] either.”	“No, nunca he tenido ninguna experiencia mala…Tampoco ella [la hija]”
	Negative experiences:
	“Personally, I never had a bad experience, but I’ve seen how other girls. like the vaccine that came out to prevent cancer. I do not agree with that one.”	“En lo personal, nunca he tenido una mala experiencia, pero he visto como otras niñas, como la vacuna que salió para prevenir el cáncer…esa no estoy de acuerdo.”
	“I had a bad experience in my country. Here I didn’t have any, but in my country the vaccines they gave them in a way it was very. it would leave a mark on them”	“Eh, yo tuve mala experiencia en mi país. Aquí no he tenido ninguna, pero en mi país, las vacunas las ponían de una manera bien, em… que se le quedaba a uno la seña.”
	“My kids, all of them, all of their vaccines they got, they never had fever. Sometimes, a vaccine they got, sometimes it makes their legs hurt, but that was all.”	“No, ninguna porque mis hijos todo ellos todas sus vacunas, las reciban ellos nunca les dio fiebre, a veces esa vacuna que les ponen que a veces los hace como que les duele su pierna sí, pero de ahí fue todo.”
	“I don’t particularly like them as young children, babies they get so many all the time”	Interview in English
Vaccine hesitancy	Among parents:
	“The truth is that when they are a baby, one does not know. But now that she is older, I think I will wait. When they are born, they give them one and that’s okay, but the rest [wait] until they are older.”	“En verdad, cuando están bebe uno no sabe, pero ahora que ya está grande yo pienso que me vera esperado. Como cuando nacen que le ponen una, está bien, pero el resto hasta que estén más grande.”
	“Well, when one is young, [one] doesn’t know what are vaccines are about. Until now, I’m more adult, I thought about studying what are vaccines. The truth is that I don’t agree with many, but I do agree with others.”	“Pues cuando uno es joven no sabe de qué se trata las vacunas. Hasta que ya ahora, estoy más adulta, pensé más como estudiar que son las vacunas. En verdad no estoy de acuerdo con muchas, pero con otras sí.”
	Among adolescents:
	“As a baby better. Because I could take her and now she doesn’t want to and sometimes we go and she doesn’t want to.”	“Cuando bebé, mejor. Porque yo la podía traer y ahorita no quiere y a veces vamos y no quiere.”
	“When she was a baby she didn’t cry as much, and now she complains about the vaccine, ‘I don’t know why I have to get them’… and as a baby, I forced her”	“Cuando bebe no lloraba tanto y ahora reniega tanto por la vacuna “no que porque me las ponen” … y bebe la obligaba”
Domain 2: Knowledge and attitudes toward adolescent vaccines
Lack of knowledge about vaccine-preventable diseases: Meningitis and pertussis	Meningitis:
	“Is that the one that affects the eyes?”	“Es como que pega en los ojos?”
	“I heard a little bit about the meningitis… That it’s a problem here. I don’t know, that it affects the throat and as I heard, I don’t know much about health but, yes, I’ve heard that meningitis is an infection, I don’t know how it happens but it affects… the neck and tonsils, I don’t know what they call it as well.”	“de que como problemas acá no se dé la garganta y según yo no mucho se de salud pero si he escuchado que la meningitis es algo una infección no sé cómo que les dan a uno acá abajo en el cuello, papera, amígdalas no sé cómo le llaman también.”
	Pertussis/whooping cough:
	“Well, it’s whooping cough! That is what it affects. But I don’t know if whooping cough is the same as asthma and all of that.”	“Bueno, es la tos ferina! Eso es lo que afecta. Pero no sé si es lo mismo de la tos ferina con el asma y todo eso.”
	“The whooping cough is a fever that my grandmother used to talk about, that this fever affects the bones and the whole body hurts and the skin turns really red and all, but that’s what I’ve heard, that’s a fever.”	“La tos ferina es una fiebre que según contaba mi abuelita de que esta fiebre le hace a uno la quebranta huesos y que le duele el cuerpo uno y que se pone bien roja la piel y todo eso no sé si será así pero si eso es lo que he oído que es una fiebre.”
Mixed knowledge about vaccine-preventable diseases: HPV	No or little knowledge:
	Q: “Have you heard of HPV, or human papillomavirus?” A: “No”	Q: “¿Escuchastes hablar del VPH o del virus del papiloma humano?” A: “No”
	“HPV is also papillomavirus? But the name of the vaccine is HPV.”	“¿El VPH que también se llama el virus del papiloma humano? Pero la vacuna se llama VPH.”
	“Yes, I’ve heard about it… Well, that they vaccinate against the papillomavirus, but I don’t know… I don’t know what it means.”	“Si, he escuchado de eso.… Pues que las vacunan contra el papiloma, pero no sé… No sé lo que significa.”
	“This is not that one in which you can lose your legs and hands, is that?”	Interview in English
	Some or a lot of knowledge:
	“Yes! It is a virus, it could cause cervical cancer and the cancer itself I guess.”	“El cáncer del cuello uterino y el cáncer pues yo creo también.”
	“That it’s, it starts with an infection… And from there, if you don’t get it treated, it will turn into cancer”	“Que es una, que empieza por una infección. Y de hay pues si no se quita esa se trata esa infección se hace cáncer.”
Mixed knowledge about vaccines	Meningococcal vaccine:
	“It’s a vaccine that I guess it’s in the…um, vagina? It’s in the vaginal area?”	Interview in English
	“That if the she gets the vaccine, she will not get this virus if it attacked some time or something. It’s preventing that.”	“Que si se vacuna, la niña no tendría este virus…que le llegara a atacar o algo. Esta previniendo eso.”
	Tdap vaccine:
	“That the vaccine…well, yes I also heard that the vaccine is against tetanus, to protect from infections.”	“Que la vacuna… Bueno, si también he escuchado que la vacuna es contra el tétano para que te proteja de infecciones.”
	“What is tetanus? When someone fall and is hurt, this one think. So, actually in the Pakistan when the child fall down and they’re scratching their knee and elbow and something else, you know, there is the vaccine, it’s not just the vaccine, you called Tdap? They are giving them every time, you know, so, it’s much better if the child get once.”	Interview in English
	HPV vaccine
	“Yes, I just know what they say, I mean I hear, I see the ad on the TV that says it’s the human papillomavirus… But in reality, I don’t know what it is… they want kids under or over 13 years to get the vaccine, I don’t know how it works.”	“Si yo nomas escucho que hablan bueno oigo, miro el anuncio en la televisión que dice que el papiloma humano…Pero no sé qué sea en realidad… Y que están queriendo vacunar a los niños menores o para arriba de 13 años no sé cómo es la cosa.”
	“That it protects from the venereal infection, which is the HPV and that it spreads by having sexual relationships. (pause) And it also relates to the papanicolaou, no?”	“Que las protege de la infección venérea que es el HPV y que se transmite teniendo relaciones. (pausa) Y tiene también que ver con el papanicolaou, ¿no?”
Lack of knowledge about daughter’s vaccination history	“I just know they vaccinated her, but I don’t know which vaccine.”	“No yo nomas sé que le pusieron una vacuna pero no se cual.”
	“They told me, but I don’t remember”	“Me dijeron pero no me acuerdo.”
	“No, I’m not sure, no…. I don’t know!”	“No, no estoy muy segura, no… No, no sé!”
	I don’t know the names.	“Los nombres, no me los sé.”
	“I don’t know, but they put it in her vaccine card. I have it there.”	“No se fíjese, como a ellas me le anotaban en la tarjetita ahí las tenía yo anotada.”
Facilitators to vaccinating	This was a requirement from the school.”	“Este una que en la escuela se las han pedido”
	“Yes, her doctor suggested she have it done.”	Interview in English
	“Doing the right thing, to prevent [HPV]… Following vaccination control while I’m responsible for her.”	“Seguir el control de vacunación, mientras yo sea responsable de ella”
	This was a requirement from the school.”	“Este una que en la escuela se las han pedido”
Barriers to vaccinating	“Because I’ve never taken her to get it. I’ve never asked about it.”	“Porque no la he llevado, nunca he preguntado.”
	“I simply don’t feel it is necessary with the necessary care. I looked for more information, what it is made of, I searched…I looked for it in Google, I studied more what it was about because they wanted to give it to my 17-year-old daughter when she turned 11 or 12 years old and I did not agree because of what the vaccine had.”	“Simplemente no la siento necesaria con los cuidados adecuados. Sí, yo busqué más información, de que está hecha, yo la busqué. la busque en Google, estudié más de que se trataba, porque mi hija de 17 querían ponérsela cuando cumplió creo que 11 o 12 años y no estuve de acuerdo por lo que traía la vacuna.”
	“…since we don’t have insurance. Only when I see it’s absolutely necessary to take her to the doctor, then we make an appointment…”	“…no tenemos seguro médico solo cuando yo veo que de verdad necesita ir al doctor es que venimos a tomar consulta…”
	“I believe the side effects it [HPV vaccine] supposedly has.”	“Yo creo los riesgos que supuestamente tiene la vacuna [HPV]”
Perceived severity	High:
	“Ah, no, it would be serious, my daughter suffers from asthma, she could die. She becomes seriously sick even with a little cough”	“Hay no sería grave mi hija sufre de asma se me muere ella con poquita tos que le pegue ella se pone grave.”
	“Fatal”	“Fatal”
	“Serious”	“Grave”
	Unsure or low:
	I don’t know	“No sé”
	Um, I think I would have to research or read to know what the risks are and try to find a solution.	“Ahm… pienso que tendría que buscar o leer a ver qué riesgos son los que lleva y tratar de buscar una solución.”
	“I don’t think it would be so bad because she would get immediate medical attention”	Interview in English
Perceived susceptibility	High:
	“Possibly yes”	Interview in English
	Unsure or low:
	“I think so, I don’t know”	“Creo que sí, no sé”
	“No, I don’t think so”	“No, no creo”
	“No, because she was receive a vaccine”	Interview in English
Domain 3: Vaccine decision-making
Mothers are the primary decision-maker; mothers have control	Mothers alone:
	“Me… she has to get it”	Yo… Se la tiene que poner.”
	“She has no control. I have the control”	Interview in English
	I make the decisions. I study a little more what is each vaccine about.	“Yo tomo las decisiones. Estudio un poco más de que se trata cada vacuna.”
	Mothers shared with spouse or doctor:
	“It’s a decision between me and her doctor”	Interview in English
	“Well, mine and that of my husband.”	“Pues, la mía y la de mi esposo”
Key influences	“Well, I think it was my decision that they vaccinated her and because she could get into her school with this vaccine. Otherwise, she would not be allowed into her school, if she didn’t have the paper signed by the doctor that gave her the vaccine.”	“Pues yo pienso que fue decisión mía que la vacunaran y porque ella pudiera entrar a la escuela con su vacuna porque si no ella no la iban a dejar entrar a la escuela si no llevaba el papel firmado por el doctor de la vacuna.”
	“[The opinion] of my family is very important.”	“[La opinión] De mi familia, es muy importante.”
	“So, I know of doctors and doctors [laughs], you know. Is important, but depends on the opinion of the doctor. I’m going to take a second opinion, I check the internet information and make a decision.”	Interview in English
	“From her doctor. Oh, and TV commercials.”	Interview in English
	“Um, I think it was really related to me, my work, what I used to see in the television, what I read on the Internet in order to make the decision.”	“Ya. Yo pienso que tuvo mucho que ver de yo, de mi trabajo, lo que miraba en la televisión, lo que leía en el internet para tomar la decisión.”
Future interest in vaccines: General acceptance of vaccines	“Cause I want her as healthy as possible”	Interview in English
	“The location doesn’t matter as long as she gets it”	Interview in English
	“Because it’s going to benefit her in many ways…”	“Porque va beneficiar a ella en muchas cosas…”
	“No, no, but I tell you that if it’s for her own good, I would like to give it to her.”	“No, no pero yo digo si es por su bien de ellos a mi si me gustaría”

Domain 1: overall attitudes toward vaccines

A major theme emerging from analyses was general acceptance of vaccines among participants. When asked “What does the word ‘vaccine’ mean to you?” the clear consensus was that vaccines are good – and some even believed that it should be necessary to vaccinate children For example, “The word vaccine, how would I say… umm, well, it should be necessary to vaccinate children.” (Table 2). Another major theme was that participants associated the word vaccine with prevention or protection. “I think is, uh, some kind of protection to prevent different kinds of diseases.” Of note, in response to this question, all answers were positive. Nobody described vaccines as harmful, dangerous, or unnecessary.

Participants described mixed experiences with vaccines in the past. While most described positive past experiences (“Well, no, everything was normal”), some discussed side effects such as soreness or pain at injection site. “I had a bad experience in my country. Here I didn’t have any, but in my country the vaccines they gave them in a way it was very. it would leave a mark on them.” Several participants indicated that they had never incurred bad past experience personally, they had witnessed adverse effects in other children. “Personally, I never had a bad experience, but I’ve seen how other girls. like the vaccine that came out to prevent cancer. I do not agree with that one.”

When participants were asked how they felt about their daughter receiving vaccines as a baby compared to as an adolescent, they generally felt the same – consistent with the themes of general acceptance of vaccines and prevention/protection. “I feel the same because I know it’s good for her health”. However, some acknowledged vaccine hesitancy among themselves or their children. A few participants indicated that they were more likely to question vaccines for adolescents, or only agreed with certain vaccines. “Well, when one is young, [one] doesn’t know what are vaccines are about. Until now, I’m more adult, I thought about studying what are vaccines. The truth is that I don’t agree with many, but I do agree with others.” Others noted increased challenges with complaints in older children. “As a baby better. Because I could take her and now she doesn’t want to and sometimes we go and she doesn’t want to.”

Domain 2: knowledge and attitudes toward adolescent vaccines

A clear theme in this domain was a general lack of knowledge regarding adolescent vaccines. Sub-themes included lack of knowledge or mixed knowledge about: 1) vaccine-preventable infectious diseases (e.g., meningococcal disease, pertussis, and HPV), 2) the meningococcal, Tdap, and HPV vaccines, and 3) daughter’s vaccination history.

With respect to vaccine-preventable diseases, half of all participants reported ever hearing of meningococcal disease or meningitis (15/30 = 50%), and a majority indicated they had heard of whooping cough (20/30 = 66.7%) (Table 3). However, there was a lot of misinformation and confusion about these two diseases. “Is that the one that affects the eyes?”; “The whooping cough is a fever that my grandmother used to talk about, that this fever affects the bones and the whole body hurts and the skin turns really red and all, but that’s what I’ve heard, that’s a fever.” There was a mixed level of knowledge regarding HPV. Most participants reported ever hearing about HPV (n = 21/30 = 70%), and some participants were able to describe its link to cervical cancer, “Yes! It is a virus, it could cause cervical cancer and the cancer itself I guess.” However, there was also a lack of knowledge about the disease. “Yes, I’ve heard about it… Well, that they vaccinate against the papillomavirus, but I don’t know… I don’t know what it means.”; “This is not that one in which you can lose your legs and hands, is that?”

Table 3. Knowledge regarding vaccine-preventable diseases, adolescent vaccines, and daughters’ vaccination history extracted from qualitative interviews.

Question	N (%)
Tdap vaccine
Have you heard of pertussis, or whooping cough?
Yes	20 (66.7)
No	9 (30.0)
Don’t know	1 (3.3)
Have you heard of the Tdap vaccine?
Yes	16 (53.3)
No	11 (36.7)
Don’t know	3 (10.0)
Has your daughter received the Tdap vaccine?
Yes	13 (43.3)
No	3 (10.0)
Don’t know/Never heard of vaccine	14 (46.6)
Meningococcal vaccine
Have you heard of meningococcal disease, or bacterial meningitis?
Yes	15 (50.0)
No	15 (50.0)
Don’t know	0 (0.0)
Have you heard of the meningococcal vaccine?
Yes	6 (20.0)
No	21 (70.0)
Don’t know	3 (10.0)
Has your daughter received the meningococcal vaccine?
Yes	5 (16.7)
No	4 (13.3)
Don’t know/Never heard of vaccine	21 (70.0)
HPV vaccine
Have you heard of HPV, or human papillomavirus?
Yes	21 (70.0)
No	9 (30.0)
Don’t know	0 (0.0)
Have you heard of the HPV vaccine?
Yes	18 (60.0)
No	12 (40.0)
Don’t know	0 (0.0)
Has your daughter received the HPV vaccine?
Yes	7 (23.0)
No	12 (40.0)
Don’t know/Never heard of vaccine	11 (36.7)

There was also a mixed level of knowledge regarding vaccines against these diseases. Few participants had heard of the meningococcal vaccine (n = 6/30 = 20.0%); among those who had heard of it, there was a lack of knowledge about the vaccine: “It’s a vaccine that I guess it’s in the…um, vagina? It’s in the vaginal area?” About half of participants reported hearing about the Tdap vaccine (n = 16/30 = 53.3%). Among those who had heard of the Tdap vaccine, knowledge was mixed: “That the vaccine…well, yes I also heard that the vaccine is against tetanus, to protect from infections.” Although most participants had heard of the HPV vaccine (18/30 = 60.0%), knowledge was limited: “Yes, I just know what they say, I mean I hear, I see the ad on the TV that says it’s the human papillomavirus… But in reality, I don’t know what it is… they want kids under or over 13 years to get the vaccine, I don’t know how it works.”

When asked which vaccines their child had received as an adolescent, many participants were unsure. A substantial number of participants did not know if their adolescent child had received the meningococcal (21/30 = 70%), Tdap (14/30 = 46.6%), or HPV (11/30 = 36.7%) vaccines. “I just know they vaccinated her, but I don’t know which vaccine.” Among participants who indicated that they had gotten their daughter vaccinated as an adolescent, most were only able to provide reasons for vaccinating or not vaccinating against HPV. Participants were unable to answer questions about vaccinating against meningococcal disease or whooping cough because they either had never heard of vaccines against these diseases or did not know if their daughter received these vaccines.

Facilitators to vaccinating against HPV included school mandates, doctor recommendation, or participants feeling responsible for keeping their children healthy. “This was a requirement from the school.”; “Yes, her doctor suggested she have it done.”; “Doing the right thing, to prevent [HPV]… Following vaccination control while I’m responsible for her.”

Barriers to vaccinating included simply not knowing about it, not thinking about it, or not asking about it; not believing it is necessary; not having health insurance; or concerns about safety and side effects. “Because I’ve never taken her to get it. I’ve never asked about it.”; “I simply don’t feel it is necessary with the necessary care. I looked for more information, what it is made of, I searched…I looked for it in Google, I studied more what it was about because they wanted to give it to my 17-year-old daughter when she turned 11 or 12 years old and I did not agree because of what the vaccine had.”; “…since we don’t have insurance. Only when I see it’s absolutely necessary to take her to the doctor, then we make an appointment.”; “I believe the side effects it [HPV vaccine] supposedly has.”

When participants were asked how bad it would be if their daughter got whooping cough, bacterial meningitis, or HPV, levels of perceived severity varied. Some participants indicated that getting these diseases would be “serious”, “fatal”, or “very bad”, while others simply did not know. A less common, but notable theme was that a few participants did not think getting these diseases would be bad, because they would either seek medical attention or search for a solution themselves. “It would probably be pretty bad, but I’m not concerned because she would get immediate medical attention.”

Perceived susceptibility to these diseases was also mixed. Some participants believed that their daughters were at risk for these diseases, “Possibly yes”; some participants did not believe their daughters were at risk, “No, I don’t think so”; and others simply did not know. A few acknowledged that their daughters were not at risk because they had been vaccinated.

Domain 3: vaccine decision-making

When participants were asked who decides whether or not their adolescent daughter receives vaccines, the clear consensus was that mothers are the primary decision-maker, and mothers have control over whether or not their adolescents get vaccinated. “Me… She has to get it”; “She has no control. I have the control.” A minority of participants indicated that their doctor or spouse shares in the decision-making. “It’s a decision between me and her doctor”; “Well, mine and that of my husband.” Very few indicated that their adolescent has some control, or that neither they nor their adolescent has any control. “I think if she doesn’t want to get it, she’s not going to get it.”; “I don’t know, because they gave it to her, nobody asked me.”

When participants were asked about sources of information and whose opinion they trust regarding whether or not their daughters should get vaccines, the prominent key influence was a doctor, “The doctor’s opinion is very important.” Other key influences mentioned were school requirements, spouse/family influences, the internet, and media:“Well, I think it was my decision that they vaccinated her and because she could get into her school with this vaccine. Otherwise, she would not be allowed into her school, if she didn’t have the paper signed by the doctor that gave her the vaccine.”; “[The opinion] of my family is very important.”; “So, I know of doctors and doctors [laughs], you know. Is important, but depends on the opinion of the doctor. I’m going to take a second opinion, I check the internet information and make a decision.”; “From her doctor. Oh, and TV commercials.”

When deciding whether or not to vaccinate their children against infectious diseases in the future, general acceptance of vaccines re-emerged as a key theme. Neither route of disease transmission nor location of administration mattered. Participants indicated interest in vaccinating their children against diseases regardless of whether they spread through the environment, coughing and sneezing, and sexual contact. Participants also indicated that they were willing to get vaccines for their daughter either from a pediatrician or local health department. “Cause I want her as healthy as possible.”; “The location doesn’t matter as long as she gets it.”

Discussion/conclusions

This study explored vaccine-related beliefs and decision-making among uninsured, predominantly Latin American immigrant mothers of daughters aged 13–17 years seeking health services at clinics that provide free health care for uninsured populations in Northern Virginia. This novel study provides a greater understanding of overall attitudes toward vaccines; knowledge and attitudes toward adolescent-specific vaccines; and vaccine decision-making among mothers of adolescent female daughters among a vulnerable, under-resourced population. Engaging women from this population in discussing their attitudes and beliefs regarding vaccinations is critical to identifying modifiable targets for interventions to increase adolescent vaccine uptake.

Participants expressed positive attitudes and high acceptability of vaccines in general, and associated the word vaccine with “protection” or “prevention”. This finding is consistent with previous research documenting favorable attitudes toward adolescent vaccinations among Latin American mothers of adolescent children.^33,36 This finding is encouraging, as it indicates that overall, uninsured mothers from a largely Latin American immigrant population might be highly receptive to interventions to increase vaccine uptake among their adolescent daughters. Although participants largely reported positive attitudes toward vaccines, our study did reveal certain attitude-related barriers to vaccine acceptability for adolescents, such as vaccine hesitancy among some mothers and challenges with vaccine-related complaints among adolescent children. Mothers who expressed more hesitancy regarding adolescent vaccines compared to childhood vaccines expressed an increased sense of agency in their ability to determine what is best for their child. They also seemed to question whether the adolescent vaccines were necessary. This finding is consistent with previous research indicating that concerns about sexuality, low-perceived risk of acquiring HPV, and social norms may act as barriers to HPV vaccination.³³ Thus, future interventions to increase vaccine uptake among adolescents should certainly acknowledge and address potential attitude-related barriers to vaccine uptake.

Another major finding was an overwhelming lack of knowledge or mixed knowledge about multiple vaccine-related issues, including, vaccine-preventable diseases, CDC-recommended vaccines for adolescents, and daughter’s vaccination history. This lack of knowledge is a major barrier to vaccine uptake among this population. While uninsured Latin American immigrant mothers might have supportive attitudes toward vaccinations in general, they cannot ensure that their adolescent children are vaccinated if they do not know what vaccines are recommended for their adolescent children, why these recommended vaccines are important, what vaccines their daughters have already received, or where to go to get recommended vaccines. In many cases, knowing about vaccines is a pre-requisite to vaccination. This finding is consistent with previous research indicating that parents from low socioeconomic backgrounds and ethnic/racial minority groups are less likely to know about the vaccines, including the HPV vaccine.^34,37 More specifically, findings are consistent with studies demonstrating that lack of knowledge and awareness are key barriers to vaccination among Latino populations.^37–42 For this priority population, interventions to increase knowledge regarding 1) vaccine-preventable diseases that affect adolescents, 2) which vaccines the CDC-recommends for adolescents, and 3) where and how to get these vaccines for no cost or low-cost are highly warranted.

Another major finding was that, when it comes to vaccinating adolescents from uninsured Latin American immigrant backgrounds, mothers are the primary decision-makers. This finding is consistent with previous research demonstrating that parents’ opinions are highly influential in determining whether or not their adolescent children are vaccinated.⁴³ Although adolescents might have more volitional control over their vaccine decision-making than younger children,⁴⁴ parents, and in this case mothers, have the ultimate ability to facilitate or inhibit vaccine uptake. Yet despite mothers’ clear role as the primary decision-maker regarding vaccines for their adolescent children, there was an apparent disconnect with knowledge about which vaccines their children had received in the past. In synthesizing data across domains, it seems that among this population, mothers are open to accepting vaccines if they believe they are safe and necessary; yet are not properly educated regarding which vaccines, exactly, their children are getting. Efforts to engage uninsured, Latin American mothers in dialogue and education regarding their daughters’ vaccination history are critical to ensure that they are able to make informed decisions about vaccination for their adolescent children.

A final finding of note was that provider’s recommendation is crucial to influence mothers’ decisions regarding whether or not to vaccinate their adolescent children. Overwhelmingly, mothers described trusting doctors, listening to doctors’ opinions, and complying with doctors’ suggestions as major determinants of vaccine uptake among their adolescent daughters. This finding is consistent with previous research demonstrating the importance of physician recommendation regarding adolescent vaccinations.^33,34,43 In addition to targeting mothers, interventions to effectively increase vaccine uptake among uninsured Latin American populations must provide education and training for physicians regarding the importance of endorsing all adolescent immunizations, including the meningococcal, Tdap, and HPV vaccines, for their adolescent patients. Furthermore, interventions are needed to train physicians regarding how to effectively communicate the importance of vaccinating in a culturally competent manner to mothers who may be from disadvantaged backgrounds.

The internet and other media (e.g., television) were also mentioned as factors influencing participants’ decision-making regarding whether or not to vaccinate their children. Misinformation and anti-vaccine rhetoric on the internet and social media sites could possibly lead to vaccine hesitancy among some mothers, particularly if they decide to search the internet for information to supplement advice from their health care providers. Disinformation and anti-vaccine messaging on the internet has been associated with key markers of vaccine hesitancy (e.g., decreased vaccine uptake and increased adverse event reporting) for multiple vaccines, including the MMR vaccine and the HPV vaccine, in developed countries.^45–49

One limitation of this study was that the geographic scope was limited to two clinics in Northern Virginia; thus, findings may not be generalizable to all uninsured Latin American immigrant populations in the United States. Next, this study only included women who were seeking health services. Attitudes toward vaccines might be systematically different among uninsured Latin American immigrant mothers who do not seek health services. Another limitation was that we did not ask any questions related to immigration status, including country of origin, amount of time living in the United States, or birthplace of the child. We did not ask these questions to maximize comfort and trust among participants; however, a notable trade-off is that we are unable to explore how these factors might have influenced vaccine attitudes or decision-making. We also did not ask questions regarding how mothers reconciled their general acceptance of vaccines with mixed past experiences regarding vaccination. Thus, we are unable to explain any discrepancies that arose. Finally, interviews guides were written in English and translated to Spanish, interviews were mainly conducted and transcribed in Spanish, and transcripts were then translated back to English for analysis. Although translators worked hard to ensure accuracy of translation, it is possible that important insights were misinterpreted in the process.

This was a novel study that explored vaccine-related knowledge, attitudes, and decision-making among uninsured, predominantly Latin American immigrant mothers of adolescent children in Northern Virginia. Findings revealed general acceptance of adolescent vaccines among this under-resourced population. Yet, despite favorable attitudes toward vaccination, participants’ understanding of adolescent vaccines and their daughters’ immunization history was limited. Findings highlight the need for efforts to help uninsured Latin American immigrant mothers better understand vaccines, and provide linkages to affordable, accessible vaccine services for their adolescent daughters. Interventions to increase vaccine-related knowledge and access among uninsured, Latin American immigrant mothers of adolescents are crucial to increasing vaccine uptake among this priority population.

Materials and methods

Participants

Participants comprised a purposive sample of 30 low-income, uninsured, predominantly Latin American immigrant mothers of adolescent daughters presenting for clinical services at one of two Mason and Partner (MAP) clinics in northern Virginia. The MAP clinics employ an academic-community partnership model, and serve uninsured populations using an integrated inter-professional treatment team approach. Eligibility criteria included: 1) being a mother or primary female caregiver for an adolescent female aged 13–17; 2) interacting with the adolescent female on a daily basis, 3) ability to provide consent and complete the study in English or Spanish, and 4) provision of written informed consent. The study protocol was approved by the institutional review board at the researchers’ institution.

Recruitment and data collection

From March–September 2016, participants were recruited from the waiting rooms at one of two MAP clinics, located in Manassas Park or Falls Church, Virginia. Trained study staff approached women to ask if they were interested in participating in a research study, consisting of a 30–60 minute interview with questions relating to vaccines for their adolescent daughters. After a mother expressed interest in study participation, she was escorted to a private location to ensure that she met eligibility criteria. Once eligibility was confirmed, a study staff member went over the informed consent form in detail, checked for participant understanding, and obtained signatures indicating informed consent. Participants were assigned anonymous study numbers that were used on all study records, rather than names. Data were collected through in-person, semi-structured interviews, in English or Spanish, by trained study staff. Interviews lasted between 30−60 minutes each, and were conducted while participants were waiting for their clinic appointments. Participants were compensated $20 in cash for their time. Interviews were audio recorded with permission, transcribed verbatim, and translated from Spanish to English for analysis. Translated interviews were then reviewed by a second translator to ensure accuracy. Transcriptions were anonymous, using only assigned study numbers.

Interview guide

Prior to conducting the interview, interviewers asked participants a short set of closed ended questions regarding demographics (e.g., age, ethnicity, education level) and child’s health history (e.g., whether the child is up-to-date with childhood vaccinations or received a flu vaccine in the past year). Interviewers then proceeded to use a semi-structured interview guide with open-ended questions to elicit participant responses. The interview guide was designed to capture four key domains regarding vaccine-related beliefs and decision-making. (Original interview guides have been added as appendices in English and Spanish). The original, pre-determined domains included 1) overall attitudes toward vaccines; 2) knowledge and attitudes toward adolescent vaccines; 3) parent-child communication; and 4) future interest in vaccines. However, upon analysis, two independent coders determined that the information fit better into three main domains: 1) overall attitudes toward vaccines; 2) knowledge and attitudes toward adolescent vaccines; and 3) vaccine decision-making. Thus, for the purpose of clarity in analyzing data and presenting study findings, parent-child communication and future interest in vaccines were combined into one major domain: vaccine decision-making. After asking initial questions as prompts, interviewers were instructed to follow up with relevant probe questions as needed.

Data analysis

For data analysis, conventional content analysis was employed.⁵⁰ Two coders independently read the first three interviews, identifying major themes in the data. The coders then met to discuss themes and develop codes. Discrepancies were discussed until a common set of codes was agreed upon. This process led to the development of an initial codebook. The coders then independently read the second three interviews, and met again to discuss themes and refine codes. The coders continued meeting after every three interviews until it became evident that no new themes were emerging (e.g., theoretical saturation was reached), after 15 interviews. Once consensus regarding the codebook was reached, the remaining interviews were analyzed independently by both coders. All transcripts were coded by both coders.

Disclosure of potential conflicts of interest

No potential conflict of interest was reported by the authors.

Interview Guide: Female Caregivers: Vaccine Decision-Making Study

Hi. My name is _________, and I will be asking you some questions about how you make vaccine-related decisions for your child. Please answer the questions honestly and accurately. All of your responses will be kept strictly confidential. There are no right or wrong answers – we simply want your opinion. Thank you so much for taking the time to share your thoughts with me today!

Let’s start with a practice question:

1) What is your favorite kind of cookie? What do you like about this cookie?

Theme 1: Attitudes toward vaccines

First, I am going to ask you some questions about vaccines.

1) What does the word “vaccine” mean to you?

a. What comes to mind when you hear this word?

b. Can you tell me about an experience (good or bad) you have had with a vaccine in the past?

c. Can you tell me about an experience (good or bad) your daughter has had with a vaccine in the past?

2) Did your daughter get her childhood vaccines as a baby (for example, against Measles)? What led to this decision?

a. How do you feel about your daughter getting vaccines as an adolescent, compared to when she received vaccines as a baby?

b. Has your daughter gotten any vaccines as an adolescent?

i. (If yes) Please tell me about the vaccines that she has received.

3) Who decides whether or not your daughter gets vaccines?

a. How much control do you and your daughter each have over the decision?

Theme 2: Knowledge and attitudes toward adolescent vaccines

Next, I am going to ask you some questions about specific diseases, and vaccines that protect against these diseases.

4) Have you heard of pertussis, or whooping cough?

a. (If yes) What have you heard?

i. Do you feel your daughter is at risk for getting pertussis?

ii. How bad would it be if your daughter got pertussis?

5) There is vaccine that protects against pertussis: The Tdap vaccine. This vaccine protects against tetanus, diphtheria, and pertussis.

a. Have you heard of the Tdap vaccine?

i. (If yes) What have you heard? Where did you hear this information?

b. Has your daughter received the Tdap vaccine?

i. What led to this decision?

ii. Who influenced your decision to get/not get your daughter the Tdap vaccine?

6) Have you heard of meningococcal disease, or bacterial meningitis?

a. (If yes) What have you heard?

i. Do you feel your daughter is at risk for getting meningococcal disease?

ii. How bad would it be if your daughter got meningococcal disease?

7) There is vaccine that protects against meningococcal disease, and complications including meningitis: The meningococcal vaccine.

a. Have you heard of the meningococcal vaccine?

i. (If yes) What have you heard? Where did you hear this information?

b. Has your daughter received the meningococcal vaccine?

i. What led to this decision?

ii. Who influenced your decision to get/not get your daughter the meningococcal vaccine?

8) Have you heard of HPV, or human papillomavirus?

a. (If yes) What have you heard?

i. Do you feel your daughter is at risk for getting HPV?

ii. How bad would it be if your daughter got HPV?

9) There is vaccine that protects against HPV: The HPV vaccine. This vaccine protects against HPV, and diseases caused by HPV (including genital warts and cervical cancer).

a. Have you heard of the HPV vaccine?

i. (If yes) What have you heard? Where did you hear this information?

b. Has your daughter received the HPV vaccine?

i. What led to this decision?

ii. Who influenced your decision to get/not get your daughter the HPV vaccine?

Theme 3: Parent-child communication

Switching gears, I would like to ask you some questions about communication with your daughter.

1) How would you describe your relationship with your daughter?

a. How much does your daughter support you in your daily life?

b. In general, how often do you make decisions together?

c. How much control do you and your daughter each have over making decisions?

d. When you and your daughter have disagreements, how are they resolved?

2) In your household, what is the process for making decisions related to your daughter’s healthcare?

a. Whose responsibility is it to stay informed about your daughter’s healthcare?

b. How comfortable are you discussing your daughter’s healthcare with her?

c. How much control do you and your daughter each have over healthcare-related decision – making?

d. If you and your daughter have disagreements about her healthcare, how are they resolved?

e. Is your involvement in your daughter’s health decision-making different for vaccines than other health-related issues (for example, diet/nutrition or taking medicine for a headache?)

f. Do you discuss your daughter’s healthcare with other adults in the household?

g. Do you discuss your daughter’s healthcare with her doctors, or other health care providers?

Theme 4: Future Interest in Vaccinations

Lastly, I would like to ask you some questions about your future interest in vaccinations.

1) Overall, how worried are you about your daughter getting infectious diseases?

2) Are you interested in getting your daughter vaccines that protect against infectious diseases?

a. Why or why not?

b. What are the reasons why you WOULD want to get your daughter vaccinated?

c. What are the reasons why you WOULD NOT want to get your daughter vaccinated?

3) Diseases can spread in different ways. Some are spread through the environment (for example, through the soil), some are spread through coughing and sneezing, and some are spread from sexual contact.

a. Does how a disease is spread matter to you?

b. Would you want your daughter to get vaccinated against diseases spread through the environment (for example, through the soil)?

c. Would you want your daughter to get vaccinated against diseases spread through coughing and sneezing?

d. Would you want your daughter to get vaccinated against diseases spread through sexual contact?

4) Some diseases can cause cancer. Would you want your daughter to get vaccinated against diseases that cause cancer?

5) Would you get a vaccine for your daughter even if you did not know what it was for?

6) Do you know where you can go to get vaccines for your daughter?

7) Whose opinion do you trust on whether your daughter should get vaccines?

a. Have you always felt this way?

8) How important is your doctor’s opinion about vaccines for your daughter?

a. How important is it for a doctor to discuss the risks and benefits of vaccines for your daughter with you?

9) How important are your family and friend’s opinion on whether your daughter should get vaccines?

10) How important is your religious leader’s opinion about vaccines for your daughter?

a. Does your religion encourage or discourage vaccinations for your daughter?

11) How important is your daughter’s view about getting vaccines?

12) The County Health Department offers free vaccines for children. Would you go to the health department to get your daughter vaccines? Why or why not?

Thank you so much for your time today! On behalf of the study team, I greatly appreciate your willingness to participate in this study.

Guía para entrevista: Madres o Tutoras: Estudio de la Toma de Decisiones Relativas a Vacunas

Hola. Me llamo _________, y voy hacer algunas preguntas sobre cómo toma las decisiones relativas a vacunas para sí mismo. Por favor, conteste las preguntas con honestidad. Todas las respuestas se mantendrán privadas. No hay respuestas correctas o incorrectas – simplemente nos gustaría saber tu opinión. Gracias por compartir tu tiempo y tus opiniones conmigo hoy!

Vamos a empezar con una pregunta para practicar:

1. ¿Cuál es tu tipo favorito de galleta? ¿Qué te gusta más en este tipo de galleta?

Tema 1: Comportamiento acerca de vacunas

Primero, yo voy hacerle algunas preguntas acerca de las vacunas.

1. ¿Qué significa la palabra “vacuna” para ti?

a. ¿Cuál es tu pensamiento cuando escuchas esta palabra?

b. ¿Me puedes contar una experiencia (buena o mala) que hayas tenido con una vacuna en el pasado?

c. ¿Me puedes contar una experiencia (buena o mala) que tu hija haya tenido con una vacuna en el pasado?

2. ¿Tu hija recibió todas las vacunas cuando bebé? (por ejemplo contra la sarampión)? ¿Qué influenció a esta decisión?

c. ¿Cómo te sientes por tu hija recibir vacunas cuando adolescente en comparación con recibir vacunas cuando bebé?

d. ¿Tu hija recibió alguna vacuna cuando adolescente? Qué piensas que influenció en esta decisión?

i. (En caso que sí) Por favor, cuéntame acerca de las vacunas que ella ha recibido.

3. ¿Quién es responsable por decidir si tu hija va recibir vacunas o no?

a. ¿Cuánto involucramiento tu y tu hija tienen en esta decisión?

Tema 2: Conocimiento y actitudes hacia las vacunas para adolescentes

Ahora, yo voy hacerle algunas preguntas acerca de algunas enfermedades especificas e de las vacunas que protegen contra estas enfermedades.

10) ¿Has escuchado hablar de pertussis o la tos ferina?

a. (En caso que sí) ¿Qué has escuchado?

i. ¿Sientes que tu hija está en riesgo de contraer la tos ferina?

ii. ¿Qué tan malo sería si tu hija tuviera la tos ferina?

11) Hay una vacuna que protege contra la tos ferina: la vacuna Tdap. Esta vacuna protege contra el tétanos, la difteria y la tos ferina.

a. ¿Has escuchado hablar de la vacuna Tdap?

i. (En caso que sí) ¿Qué has escuchado hablar? Dónde escuchaste esta información?

b. ¿Tu hija recibió la vacuna Tdap alguna vez?

i. ¿Qué piensas que influenció en esta decisión?

ii. ¿Quién influenció tu decisión acerca de la vacuna Tdap?

12) ¿Escuchaste hablar de la enfermedad meningocócica o la meningitis bacteriana?

a. (En caso que sí) ¿Qué escuchaste?

i. ¿Sientes que tu hija está en riesgo de contraer la enfermedad meningocócica?

ii. ¿Qué tan malo sería si tu hija tuviera la enfermedad meningocócica?

13) Hay una vacuna que protege contra la enfermedad meningocócica y sus complicaciones: La vacuna meningocócica.

a. ¿ Escuchaste hablar de la vacuna meningocócica?

i. (En caso que sí) ¿Qué escuchaste? ¿Dónde escuchastes esta información?

b. ¿Tu hija recibió la vacuna meningocócica alguna vez?

i. ¿Qué piensas que influenció en esta decisión?

ii. ¿Quién influenció tu decisión acerca de la vacuna meningocócica?

14) ¿Escuchaste hablar del VPH o del virus del papiloma humano?

a. (En caso que sí) ¿Qué escuchaste?

b. ¿Sientes que tu hija está en riesgo de contraer el VPH?

i. ¿Qué tan malo sería si su hija tuviera el VPH?

15) Hay una vacuna que protege contra el VPH: la vacuna VPH. Esta vacuna protege contra VPH y otras enfermedades causadas por el VPH (incluyendo verrugas genitales y cáncer de cuello uterino).

a. ¿ Escuchaste hablar de la vacuna VPH?

i. (En caso que sí) ¿Qué escuchaste? ¿Dónde escuchaste esta información?

16) ¿Tu hija recibió la vacuna VPH alguna vez?

i. ¿Qué piensas que influenció en esta decisión?

ii. ¿Quién influenció tu decisión acerca de la vacuna VPH?

Tema 3: Comunicación Madres-Hijas

Abordando otro asunto, me gustaría hacerle algunas preguntas acerca de la comunicación con tu madre o tutora.

3) ¿Cómo describiría tu relación con tu hija?

a. ¿Cuánto apoyo tiene de tu hija en tu vida diaria?

b. En general, ¿con qué frecuencia toman decisiones juntas?

c. ¿En qué medida tienes control por sobre las decisiones de tu hija y en qué medida ella tiene control también?

d. Cuando tu y tu hija tienen desacuerdos, ¿cómo ellos se resuelven?

4) En su hogar, ¿cómo es el proceso para tomar decisiones acerca de salud de tu hija?

a. ¿De quién es la responsabilidad de actualizar los datos de salud de tu hija?

b. ¿En qué medida discutes los cuidados de salud de tu hija con ella?

c. ¿En qué medida tienes control por sobre las decisiones de tu hija y en qué medida ella tiene control también acerca de las decisiones de salud?

d. Cuando tu y tu hija están en desacuerdo acerca de decisiones de salud relativas a ella, ¿cómo hacen para resolver?

e. Tu involucramiento es diferente para la tomada de decisiones relativas a las vacunas de tu hija en comparación con otro tema de salud (por ejemplo, dieta/nutrición o un medicamento para dolor de cabeza?)

f. ¿En qué medida discutes los cuidados de salud de tu hija con otros adultos en tu hogar?

g. ¿En qué medida discutes los cuidados de salud de tu hija con tus médicos y otros profesionales de salud?

Tema 4: El interés futuro en Vacunas

Por último, me gustaría hacerle algunas preguntas acerca de su futuro interés en vacunas.

13) En general, que tan preocupada te sientes acerca de su hija contraer enfermedades infecciosas?

14) ¿Estás interesada en vacunar tu hija contra enfermedades infecciosas?

a. ¿Por qué o por qué no?

b. ¿Cuáles son las razones del por qué QUERRIAS vacunar tu hija?

c. ¿Cuáles son las razones del por qué NO QUERRIAS vacunar tu hija?

15) Hay enfermedades que se pueden propagar de diferentes maneras. Algunas se propagan por el medio ambiente (por ejemplo, mediante la tierra), algunas son propagadas por medio de la tos o el estornudo, y algunas son propagadas por contacto sexual.

a. ¿Te importa el como una enfermedad se propaga?

b. ¿Querrías vacunar a tu hija contra enfermedades que se propagan por medio del ambiente (por ejemplo, mediante la tierra)?

c. ¿Querrías vacunar a tu hija contra enfermedades que se propagan por medio de la tos o el estornudo?

d. ¿Querrías vacunar a tu hija contra enfermedades que se propagan por contacto sexual?

16) Algunas enfermedades pueden causar cáncer. ¿Querrías vacunar a tu hija contra enfermedades que causan cáncer?

17) ¿Querrías vacunar a tu hija incluso sin saber para qué es?

18) ¿Tú sabes a dónde puedes ir a recibir las vacunas para tu hija?

19) ¿Con la opinión de quién confías de si deberías vacunar tu hija?

a. ¿Siempre te has sentido de esta manera?

20) ¿Qué tan importante es la opinión de tu doctor sobre vacunar tu hija?

a. ¿Qué tan importante es para un médico discutir los riesgos y beneficios de las vacunas contigo?

21) ¿Qué tan importante son las opiniones de tu familia y amigos de si deberías vacunar tu hija?

22) ¿ Qué tan importante es la opinión de tu líder religioso sobre las vacunas para tu hija?

a. ¿Tu religión anima o desanima la vacunación para tu hija?

23) ¿Qué tan importante es el punto de vista de tu hija sobre las vacunas?

24) El departamento de salud del condado ofrece vacunas gratis para los niños o menores. ¿Iría al departamento de salud para vacunar tu hija? ¿Por qué o por qué no?

Gracias por su tiempo conmigo hoy! En nombre del equipo de estudio, agradezco mucho su participación en este estudio.