Abstract
Introduction
HPV vaccination is crucial for preventing HPV-related cancers, yet rates remain below target, particularly among ethnic and immigrant communities in the United States (U.S.), where systemic barriers contribute to disparities. While research on HPV vaccination in Latino populations is growing, immigrants from Northern Triangle—El Salvador, Guatemala, and Honduras—are underrepresented. This study explored multilevel barriers and facilitators to HPV vaccination among Central American immigrant parents, a largely understudied group in vaccine research.
Methods
This qualitative, descriptive, exploratory study used in-depth, semi-structured interviews, guided by the Social Ecological Model (SEM) and the Health Belief Model (HBM). These frameworks informed the interview guide and analysis, capturing multilevel influences (SEM) and individual perceptions of susceptibility, severity, benefits, and barriers (HBM). Thematic analysis, using inductive and deductive approaches in MAXQDA, was organized by SEM levels, with HBM constructs integrated to interpret intrapersonal beliefs shaping vaccination decisions.
Results
Fifty-six parents (33 mothers, 23 fathers; mean age = 42.7 years) participated; nearly all (92.8%) were foreign-born (average U.S. residency = 17.3 years) from El Salvador, Guatemala, and Honduras. They had 77 children (ages 11–17). About 33% of children had received an HPV vaccine recommendation from a healthcare provider, and all who received a recommendation initiated vaccination (≥1 dose). Analysis revealed a complex interplay of intrapersonal, interpersonal, organizational, community, and policy-level factors. HBM constructs highlighted how perceived susceptibility, severity, benefits, and barriers influenced decisions. Key themes included knowledge gaps, cultural norms, institutional support, and systemic barriers impacting uptake.
Conclusions
Findings underscore the need for multilevel approaches to vaccination decision-making among immigrant populations. Interventions should integrate SEM and HBM perspectives, combining culturally relevant education, family and provider support, community-driven initiatives, and supportive policies to enhance vaccine literacy, build trust, reduce barriers, and increase HPV vaccine acceptance and coverage among Central American immigrants in the U.S.
Keywords
Introduction
Human papillomavirus (HPV) vaccination is a key public health measure for preventing HPV-related cancers. 1 However, HPV vaccination rates remain below target, particularly among ethnic minority and immigrant communities in the United States (U.S.), where systemic barriers contribute to disparities in cancer prevention.2-4 Barriers such as limited healthcare access, cultural differences, and low awareness contribute to these disparities.5-8 Systemic factors like socioeconomic status, lack of insurance, and language barriers further hinder efforts to achieve equitable vaccine coverage and protect these populations from HPV-related cancers.5-8
HPV infection and related cervical cancer pose a particularly high burden in Central America. For example, cervical cancer incidence in Guatemala is approximately 20 cases per 100,000 women per year, and in Honduras, about 19.1 per 100,000. 9 High-risk HPV prevalence among women in these countries ranges from 12–33%, with some populations showing rates as high as 50%.10,11 These epidemiological patterns highlight the urgent need to address barriers to HPV vaccination, particularly among Central American immigrant populations in the U.S., to reduce HPV-related cancer risk.
The Social Ecological Model (SEM) highlights how multilevel influences—individual, interpersonal, community, organizational, and policy—shape HPV vaccination behaviors. 12 Guided by this framework, HPV vaccination can be understood as the result of interacting factors across these levels rather than solely individual choice. Complementing the SEM, the Health Belief Model (HBM) provides a lens to examine parents’ perceptions of susceptibility, severity, benefits, and barriers related to HPV vaccination. 13 Together, these frameworks underscore the importance of addressing both structural and individual determinants to increase HPV vaccine uptake.
HPV vaccine uptake among ethnic minority and immigrant populations, particularly Central American and other Latino communities in the U.S., is shaped by a complex interplay of individual, cultural, social, and structural factors. One significant barrier for these groups is the lack of knowledge about the HPV vaccine, its benefits, and its safety.14,15 Many individuals in these populations may not be aware of the vaccine’s role in preventing HPV-related cancers, particularly in the context of immigrant communities where health literacy may be lower and language barriers persist. In addition, limited access to accurate, linguistically appropriate information can further constrain understanding and informed decision-making.
Furthermore, cultural beliefs and perceptions of vaccines can influence attitudes toward vaccination. Some ethnic groups may view vaccines with skepticism due to historical mistrust of the healthcare system, particularly among immigrant populations who may have experienced discrimination or marginalization in their home countries.16-18 This mistrust can result in vaccine hesitancy, making it more difficult for public health campaigns to successfully promote vaccination. 7 In some cases, there may also be concerns about the perceived relevance of the vaccine, as individuals may not view HPV vaccination as necessary or culturally appropriate, especially in populations where discussions about sexual health are stigmatized or taboo.7,16
Access to healthcare is also crucial for HPV vaccine uptake. 8 Immigrant populations, especially those with limited English proficiency or unstable immigration status, face significant barriers, including lack of insurance, high out-of-pocket costs, and living in underserved areas. 8 Additionally, healthcare provider (HCP) recommendation is a key factor in vaccine uptake, but immigrant populations often have less frequent access to providers who can offer guidance and encourage vaccination.7,16
Cultural and linguistic barriers between healthcare providers and ethnic minority populations often hinder patients’ access to essential information for informed decision-making.5,7,16 Addressing these barriers requires improving healthcare access and ensuring services are culturally competent and responsive to the needs of immigrant and minority communities.2,16-22 Once these barriers are overcome, community support from leaders and family can help build trust and encourage vaccine uptake.7,16
While research on HPV vaccination in Latino populations is growing, immigrants from the Northern Triangle—El Salvador, Guatemala, and Honduras—remain underrepresented.23-25 Most studies aggregate Latin American subgroups, overlooking the unique social, economic, and cultural factors affecting Northern Triangle immigrants. This gap limits our understanding of how these factors shape HPV vaccination decisions across specific subgroups.26-32 Therefore, this study aims to fill this gap by exploring the multilevel barriers and facilitators to HPV vaccination among Central American immigrant parents, a largely understudied group in vaccine research.
Methods
This qualitative study, guided by the SEM 12 and the HBM, 13 is part of a larger mixed-methods research project exploring factors influencing HPV vaccine uptake among Central American parents from El Salvador, Guatemala, and Honduras (Northern Triangle countries). The reporting of this study conforms to the COREQ guidelines for qualitative research. 33
Data were collected from U.S. states with significant Central American immigrant populations, including California, Florida, Texas, New York, New Jersey, Illinois, Maryland, Virginia, Arizona, and Massachusetts to capture variations in access to healthcare and vaccine information.32,34,35 The U.S. states selected as the focus of the study was based on a review of publicly available demographic data (e.g., U.S. Census and American Community Survey reports), and those with relatively large proportions and absolute numbers of Central American residents were chosen.
The study setting primarily included urban communities within these states, focusing on neighborhoods with high concentrations of Central American immigrant families. These settings provided culturally relevant contexts for understanding participants’ experiences and decision-making regarding HPV vaccination.
Researcher Characteristics and Reflexivity
The research team consisted of all female researchers and one male research assistant, all Latin American and bilingual (Spanish and English). Three of the seven team members were born in El Salvador, Guatemala, and Honduras, and all were bicultural. Two additional members—the principal investigator (PI) and a data analysis team member—were also Latin American (Brazilian) and fluent in Spanish; both are PhD professors at a university and did not participate in data collection. The remaining five members included one female PhD candidate and four undergraduate students, all trained by the two PhD professors and with previous experience in participant recruitment. The two interviewers—the PhD candidate and a senior undergraduate—conducted all interviews and had prior training and experience with qualitative data collection involving immigrant Latino populations. The team engaged in reflexive discussions and journaling to consider their positionality and potential biases. This composition facilitated culturally and linguistically appropriate interactions during interviews while ensuring consistency and confidentiality.
The team carefully considered their relationship with participants throughout the study. Participants were informed about the researchers’ roles, credentials, and the purpose of the study at the beginning of each interview. All interactions were guided by principles of trust, confidentiality, and cultural competence, and no prior relationship existed between the interviewers and participants. Reflexive discussions and journaling were used to acknowledge potential biases and to ensure that participants’ perspectives were accurately represented.
Study Design
A qualitative, descriptive, and exploratory approach was used to examine multilevel influences on HPV vaccine knowledge, attitudes, and behaviors among Central American parents in the U.S.36,37 The goal was to understand the factors shaping vaccination decisions, with a focus on cultural, social, familial, and healthcare-related influences, as well as barriers and facilitators to vaccine uptake.
Qualitative research is key to understanding the contextual, cultural, and personal factors driving vaccine decisions, especially in minoritized populations with limited prior research. 37 It provides in-depth insights into individual and community experiences, revealing barriers and facilitators not captured by quantitative methods. 37
The present study used the SEM 12 and the HBM 13 as frameworks to examine how intrapersonal, interpersonal, community, organizational, and policy-level factors influence HPV vaccination decisions. The HBM specifically guided the exploration of parents’ perceptions of susceptibility to HPV, perceived severity of HPV-related diseases, perceived benefits and barriers to vaccination, and self-efficacy in obtaining the vaccine. By integrating these models with qualitative methods, the study aimed to identify multilevel factors shaping vaccination decisions among underserved ethnic populations, providing insights to guide the development of culturally tailored interventions.12,37
Sample and Participant Recruitment
The study focused on Central American parents from El Salvador, Guatemala, and Honduras with at least one child aged 11–17 years. Participants were purposively selected to ensure representation of Central American immigrant parents from El Salvador, Guatemala, and Honduras, capturing diversity in gender, age, immigration status, and HPV vaccine knowledge. 37
Eligibility criteria included: (1) Self-identified aforementioned Central Americans from El Salvador, Guatemala, or Honduras; (2) 21 years or older; (3) at least one child aged 11–17, with age 11 selected as the lower bound to align with routine clinical and public health recommendations for HPV vaccination, which typically target children aged 11–12 as part of the standard adolescent immunization schedule (CDC, 2023); (4) fluent in Spanish and/or English; (5) willing to provide informed consent for audio recording; (6) residing in the U.S. for at least six months, to ensure participants had some exposure to the U.S. healthcare system and could reflect on relevant experiences; although we did not confirm specific healthcare interactions during screening, prior studies suggest that most parents residing in the U.S. for this duration have accessed healthcare services23,32; and (7) only one parent per family was eligible to participate to ensure that each participant represented a unique family unit.
The target sample size was 40–50 parents, with a quota established to include roughly equal representation of mothers and fathers to capture diverse perspectives. Data saturation was monitored throughout data collection, defined as the point at which no new themes, codes, or insights emerged.
Participants were recruited through community organizations, healthcare clinics, churches, social media, and events serving Central American immigrants, using successful recruitment methods from prior research with Latino and Central American populations.32,35 Recruitment included direct outreach by research staff and network sampling, where enrolled participants referred others. Recruiters documented recruitment strategies and field notes to enhance transparency and reflexivity. Staff members, embedded in the Central American community, leveraged personal networks to facilitate recruitment, ensuring a diverse sample with varying levels of HPV vaccine knowledge.32,35 Most participants were recruited from urban areas in Greater Boston, which has a large Central American immigrant population.
Recruitment began on June 30, 2023, and concluded on October 20, 2023. Data collection occurred concurrently with recruitment, with participants interviewed shortly after enrollment.
Data Collection
In-depth, semi-structured interviews were conducted via Zoom to explore factors influencing HPV vaccination decisions. All interviews were individual sessions, with only one parent per family participating, allowing participants to share their perspectives freely without influence from a partner.
Prior to the interview, a brief survey was administered online via Qualtrics to collect basic socio-demographic and cultural data, including age, marital status, education, household income, number of children aged 11–17, primary language spoken at home, and length of U.S. residence. Acculturation was measured using the Short Acculturation Scale for Hispanics (SASH), a validated 12-item tool assessing language use, media preferences, and ethnic social relations, with good reliability (Cronbach’s alpha: 0.89–0.92).38,39 An acculturation score was calculated by averaging the 12 items, with scores above 2.99 indicating higher acculturation.
All participants were informed about the study purpose and procedures at the start of each interview, including their right to withdraw at any time. Informed consent was obtained electronically. Participants were offered the choice of Spanish or English, and all chose Spanish.
Interviewers used a semi-structured guide developed based on the SEM
12
and HBM
13
and pilot-tested with two parents not included in the final sample to refine questions and ensure cultural relevance. The interview guide explored: • • • • •
Interviews lasted 45–60 minutes and were conducted by trained bilingual researchers via Zoom, allowing participants to engage from the safety and comfort of their homes. 36 Field notes were taken during and immediately after each interview to document context relevant to interpretation.36,40 All interviews were audio-recorded with participants’ consent to ensure accurate data capture and facilitate thorough analysis.
Data Analysis
Interview data were analyzed using the SEM 12 and the HBM. 13 The SEM highlights multi-level factors—intrapersonal, interpersonal, community, organizational, and policy-level—that influence HPV vaccination knowledge, attitudes, and behaviors, while the HBM focuses on parents’ perceptions of susceptibility, severity, benefits, and barriers that shape vaccination decisions.
All interviews were transcribed verbatim in Spanish by a native speaker and anonymized for analysis. The research team first reviewed transcripts and recordings to become familiar with the data.36,40 A preliminary codebook was developed based on SEM and HBM constructs and refined iteratively as new concepts emerged. Audit trails of coding decisions and theme development were maintained to enhance trustworthiness.36,40
Initial open coding identified key concepts aligned with the SEM’s ecological levels: individual-level codes captured personal knowledge of HPV; interpersonal codes focused on family and social network influences; community-level codes reflected cultural norms and healthcare access; and organizational-level codes emphasized healthcare providers’ roles.36,37,40 Two team members independently coded all transcripts, with no exclusions. Coding discrepancies were discussed in weekly meetings and resolved through consensus, and the codebook was updated to maintain consistency. 40
Codes were then grouped into broader themes and subthemes that aligned with SEM levels and HBM constructs (e.g., perceived susceptibility, severity, benefits, and barriers). Examples of themes included personal knowledge (individual), family support (interpersonal), and cultural influences (community/organizational). This process revealed how multiple levels interacted to shape vaccination decisions. Data were organized using MAXQDA software, 41 and themes were mapped to SEM and HBM constructs to contextualize findings within a multi-level framework.12,13
In the final phase, themes were interpreted in relation to the study’s research questions and existing literature, with the SEM and HBM guiding understanding of how each level influenced parents’ decisions.12,13,36,40 Findings were presented within this multi-level context, emphasizing the need for culturally responsive interventions to improve vaccine uptake in immigrant communities.
Descriptive analysis of socio-demographic data from the pre-interview survey was also performed. Categorical variables (e.g., marital status, education) were compared using chi-square tests, while continuous variables (e.g., age, acculturation score) were compared using independent samples t-tests. P-values indicate differences between mothers and fathers for each variable.
Ethical Considerations
Ethical approval for this study was granted by the Institutional Review Board of the University of Massachusetts Boston (Protocol No. #30362022047; approval date: March 10, 2022). All study procedures involving human participants were conducted in accordance with the ethical standards of the approving Institutional Review Board and with the Declaration of Helsinki of 1975, as revised in 2024.
All participants provided informed verbal consent prior to participation, which was documented and witnessed by a member of the research team. Participants were assured of confidentiality through the anonymization of identifying information. All data were fully de-identified to ensure that no individual participant could be identified. Data were securely stored and accessible only to authorized members of the research team. Participants were informed that they could withdraw from the study at any time without penalty or consequences.
Results
Sociodemographic Characteristics of the Sample
Sociodemographic and Cultural Characteristics of the Sample (N = 56)
Nearly all parents (92.8%) were born outside the U.S., mainly from El Salvador (32.1%), Guatemala (32.1%), and Honduras (28.6%). Foreign-born parents had lived in the U.S. for an average of 17.3 years, with 42.9% residing there for 20+ years. Almost 84% spoke Spanish at home. Most parents lived in Massachusetts (66.1%), with the rest in other U.S. states. About 58.9% identified as Catholic. Regarding healthcare, 57.1% had public insurance, while 16.1% were uninsured.
Seventy-seven unique children aged 11-17 years were represented across the 56 parents recruited for this study with most parents having one child in this age group (69.6%). The mean age of the children was 14.3 years (SD = 2.1). The gender distribution was 57.1% male and 42.9% female. All parents reported that all their children had a healthcare provider. About 33.8% of parents reported that their child’s healthcare provider recommended the HPV vaccine, and all children who received a recommendation were vaccinated. More female children (42.4%) received the vaccine compared to male children (27.3%).
Emergent Themes
Analysis of the interviews identified key multilevel factors shaping parents’ HPV vaccination decisions. Findings are presented according to levels of influence, highlighting individual beliefs, family and social dynamics, organizational and community contexts, and broader policy-related factors.
Intrapersonal Level Influences
The analyses identified two key intrapersonal themes shaping parents’ HPV vaccination decisions: 1) limited knowledge and information gaps in HPV awareness and vaccination decisions; and 2) parental misunderstandings and safety concerns about vaccination.
Theme 1: Limited Knowledge and Information Gaps in HPV Awareness and Vaccination Decisions
Parents frequently reported limited knowledge about HPV, its connection to cancer, and the HPV vaccine, which influenced their vaccination decisions. Many participants, both mothers and fathers, expressed uncertainty or lack of familiarity with the virus and vaccine. For example, one mother stated, “I think people sometimes don’t do it due to lack of information… maybe because of fear, maybe because they don’t understand” (Mother #1), illustrating how insufficient knowledge can lead to reluctance or confusion. One father noted, “Well, the only barrier I have so far is more information” (Father #30), suggesting that additional education could address concerns and misunderstandings. Other participants expressed uncertainty, with one mother saying, “I don’t know much about the topic, so I still don’t know what decision to make” (Mother #3), and another simply stating, “Honestly, I don’t know” (Mother #6).
Critical knowledge gaps affecting vaccination decisions were apparent. Many parents indicated they needed more information to make informed choices. Some fathers, in particular, demonstrated greater gaps in awareness compared to mothers. For example, one father explained, “I’ve heard of it, yes, but I haven’t really paid much attention and don’t know much about it” (Father #26), while another admitted, “Actually, I don’t know what human papillomavirus is” (Father #35). One father reflected, “Actually, no, not until you mentioned it to me” (Father #30). This highlights a potential trend in gender differences in awareness, though overall, parents across genders reported significant information gaps.
Some parents reported that their first exposure to HPV and the vaccine occurred during the study itself, with one mother saying, “The first time I heard about human papillomavirus was from you guys” (Mother #1), and another admitting, “I have no knowledge of this” (Mother #3). One father emphasized the desire to learn more, stating, “I would like to inform myself more… where this disease comes from” (Father #30).
Theme 2. Parental Misunderstandings and Safety Concerns Surrounding the HPV Vaccine
Some parents expressed concerns about the safety of the HPV vaccine and reported misunderstandings about its purpose, which shaped their individual vaccination decisions. Several participants voiced discomfort with vaccinating children at an early age due to perceived risks. One mother reflected on her apprehension, saying, “There are always risks in life, but my trust isn’t really in human medicine” (Mother #11), highlighting a broader internal mistrust of medical interventions. Another parent acknowledged the complexity of the vaccine, stating, “Well, the truth is, I think only the scientists who developed the vaccine and studied the disease fully understand the terms and guidelines” (Mother #16), illustrating reliance on expert knowledge but limited confidence in her own understanding.
Some parents feared that the vaccine might lead to early sexual activity, with one mother expressing, ‘I worry that giving this vaccine could make my daughter think it’s okay to be sexually active too soon’ (Mother #14). However, others expressed positive views when they trusted the source. One mother explained, “Yes, yes, I trust because, um, I already got it, and so far, I haven’t had any problems” (Mother #2), demonstrating that personal experience can build trust. These findings underscore that parents’ hesitations stem from personal beliefs, perceived risks, and internalized uncertainty about vaccine safety.
Interpersonal Influences on HPV Vaccination Decisions
At the interpersonal level, four key themes emerged that influenced HPV vaccination decisions: 1) influence of family and spouse in vaccination decisions; 2) peer influences on vaccination decisions; 3) sexual health concerns in vaccination decisions; and 4) trust in healthcare providers and the need for more guidance. These themes are discussed in more detail below.
Theme 1. Influence of Family and Spouse on Vaccination Decisions
Parents highlighted the significant role of family relationships, especially with spouses, in shaping vaccination decisions. These decisions were often centered on protecting daughters. One father explained, “My wife told me years ago… kids will be vaccinated against papillomavirus because kids start sexual activities earlier, and to protect them” (Father #40). Many parents, especially those with daughters, noted joint decision-making. As one father said, “It was a joint decision” (Father #51).
However, spousal involvement varied, reflecting gendered dynamics. Mothers, often the primary caretakers, typically took full responsibility for health decisions, with some emphasizing their autonomy. One mother stated, “I am the one who makes the decision” (Mother #24), while another said, “I’m in charge of everything. My husband only works” (Mother #4). Fathers usually played a passive role, with one remarking, “My wife usually goes to the clinic with them, but she hasn’t asked me about it” (Father #45). These dynamics show that mothers often lead health decisions, while most fathers defer to wives or healthcare providers.
Some parents considered their children's preferences, while others made decisions themselves. One mother said, “I would talk to my children if they wanted to get it… it’s their body, and they decide” (Mother #16). A few parents noted that their child was too young to participate in the decision, emphasizing that it was the parents’ responsibility to decide. However, many parents didn’t prioritize their children's opinions. One mother noted, “I haven’t talked about vaccinating my child; vaccines are important to me” (Mother #1), and another father added, “The kids hardly ever have an opinion. We tell them, ‘You’re getting it because it’s good for you’” (Father #26).
While parents varied in including their children in vaccination decisions—sometimes influenced by the child’s age—peer and social influences from outside the immediate family also shaped perceptions and discussions about the HPV vaccine.
Theme 2. Peer Influences on Vaccination Decisions
While most participants reported not discussing HPV vaccination with individuals outside their immediate family, the influence of social networks and peers was still evident. Some parents described how friends, coworkers, or community members could shape perceptions indirectly, though many emphasized that their decisions were ultimately personal. One mother explained, “No, it doesn’t influence me. I am a person who […] I don’t let myself be influenced by people; I look for information” (Mother #8), while another stated, “Everyone has their point of view and opinions, so you hear what people say, but at the end, I am the one who makes the decision” (Mother #24).
Peer influence was sometimes apparent in situations where differing opinions arose, leading to discussions or minor disagreements. One father acknowledged, “Sometimes it even leads to arguments because we all think differently […] and we need to respect that […]” (Father #45). These disagreements appeared to provide parents with alternative perspectives to consider, rather than directly influencing their final decision-making. Overall, parents recognized that their social environment could offer information or viewpoints, but personal judgment and reflection remained central to whether they chose to vaccinate their children against HPV. While peers provided context and perspectives, parents emphasized that interpersonal discussions alone were not enough to shape their final vaccination decisions, as concerns about sexual health and vaccine timing also played an important role.
Theme 3. Sexual Health Concerns in Vaccination Decisions
Some parents were particularly uneasy about offering the HPV vaccine to children due to its connection to sexual health. One mother expressed her discomfort, saying, “My concern was, why were they offering a vaccine like this to a child?” (Mother #18), highlighting unease with introducing a vaccine related to sexual health at a young age.
These concerns were closely tied to interpersonal influences, including discussions with family members, guidance from spouses, and trust in healthcare providers. For some parents, personal experience and trust in the source mitigated these concerns. As one mother explained, “I felt more confident because my sister had her child vaccinated, and the doctor walked me through everything step by step” (Mother #7). This theme highlights that parents’ hesitations regarding sexual health are shaped by social context and relationships, rather than solely by misunderstandings of the vaccine itself.
While sexual health concerns influenced parents’ hesitations, many still relied on trusted healthcare providers for guidance, highlighting the need for clear and supportive recommendations from professionals.
Theme 4. Trust in Healthcare Providers and the Need for More Guidance
While parents acknowledged the influence of peers and their own prior experiences, many highlighted that trusted healthcare providers were central to their vaccination decision-making. Healthcare providers were key influencers in many parents' vaccination decisions, with parents expressing trust in information from qualified healthcare providers such as doctors and nurses. One mother said, “Well, with a qualified doctor. A doctor who is qualified to give you good information” (Mother #13). A father added, “If the doctor, the nurse says that, uh, it’s okay, yes, of course” (Father #48). However, some parents noted that the advice they received from healthcare providers could vary. One parent mentioned, “I think it may depend on the doctor and the physical condition and maybe the human condition […]” (Mother #2).
Despite this trust, many parents still made decisions based on their own research and judgment. For example, one father mentioned, “If they told me there is this type of vaccine, then I would have to look for some information… that is, research about the vaccine” (Father #44). Several parents expressed a desire for more direct guidance from healthcare professionals. One mother suggested, “It would be more helpful if they told people, ‘Look, I’m going to give you this vaccine; these are the possible effects,’ because sometimes people can’t even read” (Mother #1), expressing a desire for more information.
Organizational Level Influences on HPV Vaccination Decisions
At the organizational level, the analyses identified four key themes that influence parents’ HPV vaccination decisions: 1) influence of schools and health services on vaccination decisions, with a sub-theme on barriers due to insufficient communication from these institutions; 2) healthcare provider workload and time pressures; 3) limitations of current information delivery methods; 4) influence of religious and community institutions on HPV vaccination. Participants highlighted both positive influences and barriers related to the communication and support provided by various institutions, including schools, health services, churches, and community centers, all of which play a significant role in shaping parents’ decisions to vaccinate their children against HPV.
Theme 1. Influence of Schools and Health Services on Vaccination Decisions
Many participants reported that schools and health services influenced their vaccination decisions by providing information and recommendations. One father shared, “I learned it at my son’s school [...]” (Father #51), indicating that educational institutions are a source of vaccination information. Similarly, a mother noted, “At school, or at the health center, they go from house to house, saying that it's good to get it, so why would we say no? They know why they give it, that it won’t harm us, and that everything will be fine” (Mother #5). Another participant mentioned, “I heard it at the hospital, and sometimes they send information from school” (Mother #21), illustrating that health services also play a key role in communicating the importance of the vaccine.
However, not all parents reported being positively influenced, and some described barriers due to insufficient or unclear communication from schools and health services. One mother explained, “I honestly don’t remember if they gave me a good explanation or not; they just told me it was the vaccine. I asked for a document explaining what it was, and they gave me a sheet. I read it at the time, and that was it” (Mother #23). This lack of detailed information led some parents to perceive the HPV vaccine as unnecessary or unimportant. One father said, “[…] if they (referring to healthcare providers) would just tell us a little bit about it (the vaccine) and why we should give it (vaccine shots) to our children and why it is important we give early (young child) we would be more willing to consider it […]”
Overall, while schools and health services provided important information that supported vaccination for some parents, gaps in communication could create uncertainty or hesitancy, highlighting the need for consistent and clear messaging. This context sets the stage for exploring how interpersonal influences, including family and peers, interact with these institutional factors in shaping vaccination decisions.
Theme 2. Healthcare Provider Workload and Time Pressures
Participants also noted that time constraints within healthcare systems affected the quality of communication between healthcare providers and patients. Several parents mentioned healthcare providers being under pressure to see a high volume of patients, which can limit the time available for discussing vaccines. Some parents reported that, as a result, they first heard about the HPV vaccine from the study rather than from their provider, highlighting a gap in provider communication. One mother pointed out, “What I see here as a real barrier is time because doctors are more interested in the number of patients they see” (Mother #16). Another father added, “The biggest inconvenience sometimes is that there’s only one person at the clinic [...] maybe they don’t discuss more topics due to lack of time. If I’m there for the measles vaccine, they’ll only tell me about measles, and that will be it” (Father #32). Parents emphasized that these time constraints not only limit discussion on routine vaccines but also prevent healthcare providers from offering detailed information on vaccines like HPV, which may require more explanation and guidance.
Theme 3. Limitations of Current Information Delivery Methods
Some participants reported that health services’ approaches to providing information were insufficient, particularly the reliance on pamphlets. Many found these passive delivery methods ineffective in influencing parents’ vaccination decisions. One mother shared, “When you arrive at the clinic, they tell you it’s time for a certain vaccine and hand you a paper. As I said, you put the paper in your wallet and don’t feel like reading it” (Mother #1). Another mother recalled, “I used to read the pamphlets at the clinic, but I don’t remember much of what they were about” (Mother #8), indicating that the information lacked engagement and was easily forgotten.
Several participants contrasted this approach with practices in their home countries, expressing a preference for more interactive and personalized education. They emphasized the need for engaging, informative strategies that could better capture parents’ attention and improve vaccination uptake. One mother explained, “They used (healthcare services in home country) to educate us about that, but here, I don’t see it. The nurse just checks your temperature, your weight, and tells you to go over there. In my country, the nurse would give a talk while we waited in the clinic, saying, ‘Today we’re going to talk about...,’ like during a dengue outbreak, for example” (Mother #23).
Theme 4: Influence of Religious and Community Institutions on HPV Vaccination
Religious institutions, particularly churches, and community centers emerged as influential social institutions that can both support and shape parents’ HPV vaccination decisions. Some participants highlighted the supportive role of churches. One mother explained, “Sometimes churches help by setting up a vaccination center if it’s really necessary” (Mother #7). Others noted that certain churches may discourage vaccination due to general distrust of vaccines, which could influence parents not to vaccinate: “Eh, the church, in general, tends to be a bit distrustful about vaccines” (Father #10). Despite these differences, many participants indicated that churches did not interfere with their decisions, and some saw them as valuable venues for disseminating health information. For example, one mother stated, “If it’s about helping people prevent diseases, it’s good to do it” (Mother #46). Another noted, “Schools, churches, and community organizations could be helpful, as they are trusted by members of the community and focus on disease prevention and health promotion” (Mother #54).
Similarly, community centers and other social institutions were viewed as key platforms for reaching broader audiences with vaccination information. One mother explained, “Community leaders and schools are important, because if it affects young people, they should know this information” (Mother #8). A father added, “Places like churches and community centers are ideal for providing health information” (Father #35), emphasizing the potential of these institutions to support public health efforts.
Community-Level Influences on HPV Vaccination Decisions
At the community level, several factors influenced HPV vaccination decisions, with four key themes emerging from the data: 1) impact of patriarchal structures on health discussions; 2) cultural and social influences on HPV vaccination; 3) the role of communication media in shaping health decisions; and 4) culturally responsive health education and community engagement.
Theme 1. Impact of Patriarchal Structures on Health Discussions
The analysis revealed that patriarchal structures within the community significantly affect how health topics, including HPV vaccination, are discussed. Some parents noted that cultural norms such as machismo and traditional gender roles often make these topics, particularly HPV vaccination, a taboo subject, especially for women. One mother explained, “Due to patriarchy, the patriarchal machismo that systematically absorbs our society and also because of ignorance… it has been a taboo since the same patriarchy and machismo don’t allow women the freedom to discuss topics of interest. Many people feel ashamed to talk about or listen to such topics” (Mother #16).
Parents also felt that these cultural dynamics create barriers to open communication and limit the exchange of information about vaccines. Many parents reported feeling more comfortable discussing health matters within informal social settings, such as with family or friends, rather than in formal settings like church. One father noted, “Uh… generally, with friends. At church, these topics are hardly discussed; it’s practically with family and friends” (Father #10).
Theme 2: Cultural and Social Influences on HPV Vaccination
Cultural norms and individual religious beliefs emerged as influential factors shaping parents’ attitudes toward HPV vaccination. These beliefs significantly impacted parents’ attitudes, either facilitating or hindering vaccine acceptance.
Sub-Theme 1: Cultural Beliefs and Communication Barriers
The analysis revealed that cultural factors played a significant role in shaping parents’ attitudes toward HPV vaccination. Beliefs about gender roles, sexuality, and traditional medical practices often influenced decision-making, with some parents acknowledging a lack of open communication about sexual health topics in their home countries. One father explained, “Sometimes we don’t have much communication, or they didn’t talk to us about protection and things like that in our countries” (Father #39), highlighting how these cultural norms may contribute to a limited understanding of topics like HPV and vaccination. Despite these cultural constraints, some parents maintained a more open perspective on the HPV vaccine. One mother shared, “I think it’s good to get the vaccine. It’s something that can help you avoid a disease. I think that’s what we should do, but it’s really up to the person and how they feel” (Mother #24), suggesting that for some, the health benefits of the vaccine can transcend cultural barriers.
Sub-Theme 2: Individual Religious Beliefs
Parents also described how personal religious beliefs could influence vaccination decisions. Some parents reported that their faith did not conflict with vaccinating their children. One mother stated, “My religion doesn’t prevent anything” (Mother #26), reflecting a view that religion and vaccination could coexist without issue. However, other parents noted that certain teachings or guidance within their faith encouraged careful consideration before accepting medical interventions. As one father explained, “In my church, people usually discuss and think carefully before accepting any medical intervention, including vaccines” (Father #10), suggesting that individual religious beliefs may shape deliberation and decision-making about the HPV vaccine.
Theme 3. Role of Communication Media in Shaping Health Decisions
The role of communication media emerged as another significant factor in shaping parents’ health behaviors, particularly regarding HPV vaccination. Participants highlighted television programs and news outlets as primary sources of information, with these local media outlets seeing as important in disseminating health-related information, especially within immigrant populations. One mother recalled, “The first time I heard about it was on a television program, I think” (Mother #24), while another father emphasized the influence of popular channels, saying, “Univision is the best program for all Hispanics, but as I tell you, the news is always sharing many things” (Father #47).
Theme 4: Culturally Responsive Health Education and Community Engagement
A key theme that emerged was the importance of accessible, culturally relevant health education in shaping parents’ knowledge and attitudes toward HPV vaccination. Many participants described challenges in accessing accurate information due to language barriers, misinformation, and limited community resources, which hindered informed decision-making. One mother reflected, “I think there’s a bit of misinformation, perhaps. That’s why we don’t pay attention to it as we should, because many times we don’t have the resources to receive the information we need in our language” (Mother #1).
Participants highlighted the value of community-driven and interactive approaches to health education. One mother recalled an effective practice from her home country of Guatemala: “In Guatemala, they used to have a specific day at the pharmacy when they would set up a loudspeaker, and doctors would come. While you were buying something, they would talk to us about diseases, explaining what could be used and why it happens” (Mother #5). Similarly, another mother shared, “I remember in my country, when we arrived at the clinics, the nurse would come and, while we waited, she would give us a talk. For example, she would say, ‘Today, we’re going to talk about... dengue, for example’” (Mother #23). These experiences demonstrate that health education integrated into familiar community spaces can be more accessible, engaging, and effective than traditional methods.
Participants suggested that structured, community-based education tailored to immigrant populations could improve access to reliable information. One mother emphasized the role of seminars, meetings, and online resources, noting, “[...] it could be seminars, meetings, and obviously, as I said, on the Internet, you can find a lot of information about this. But yes, sometimes it’s important... I believe the experiences of one person can speak for a group” (Mother #1). A father reinforced the importance of community input, stating, “The advice, I think, in communities here […] when you hear from others in your community at least you become informed […]” (Father #31). Churches and community centers were also identified as potential platforms for disseminating vaccination information, with one mother commenting, “If it’s about helping people prevent diseases, it’s good to do it” (Mother #46).
Overall, participants emphasized that culturally responsive health education delivered through trusted community settings—such as clinics, pharmacies, community centers, and religious institutions—can empower parents to make informed vaccination decisions and overcome barriers related to language, culture, and misinformation.
Policy Level Influences on HPV Vaccination
At the policy level, two key factors influenced HPV vaccination decisions: 1) the impact of vaccination mandates; and 2) the role of public health policies in promoting vaccination.
Theme 1: Impact of Vaccination Mandates
The analysis revealed that legal requirements, such as school-entry vaccination mandates, significantly influence parents’ vaccination decisions. Many participants acknowledged that when vaccination is mandated for school enrollment, they comply, often out of necessity rather than choice. One mother explained, “The physical exam for school entry, because you are required to bring the physical form to school. So, it’s a good way to mandate the vaccine and also to provide an educational session” (Mother #21). However, there was also concern about the potential for future mandates, with some parents expressing reservations. As one father shared, “I’m not sure, as I told you, I think they will make it mandatory in schools, for them to be vaccinated. I think it’ll be in California. So, I don’t like it” (Father #40).
Theme 2: Role of Public Policies in Promoting Vaccination
Participants shared experiences and ideas related to public health policies that support vaccination. For example, one mother described health education practices in her home country, saying, “In my hometown in Brazil, the local clinic used to hold weekly sessions where nurses and doctors would explain different health topics to everyone waiting, including vaccines” (Mother #12). Similarly, a father noted potential benefits of broader healthcare supports, stating, “Well, for instance, if they increased the number of doctors or conducted more studies on the matter” (Father #54).
These quotes reflect participants’ recognition of practices and support at the community or system level, such as education programs and access to healthcare professionals. While parents did not explicitly describe specific U.S. public policies, their observations highlight how structural supports in healthcare and education can influence awareness and decision-making regarding vaccination.
Discussion
This qualitative study examined the multilevel factors influencing HPV vaccination decisions among Central American immigrant parents in the U.S., guided by both the Social Ecological Model (SEM) and the Health Belief Model (HBM).12,13 SEM allowed us to explore influences at the intrapersonal, interpersonal, organizational, community, and policy levels, while HBM provided insight into how parents’ perceptions of susceptibility, severity, benefits, and barriers shaped their vaccination decisions.12,13 We identified a complex interplay of factors, including individual knowledge, cultural norms, institutional support, and systemic barriers. Below, we discuss the implications of these findings within each level of influence.
At the intrapersonal level, significant gaps in HPV knowledge were found, particularly among fathers, with many unaware of the virus’s connection to cancer, which directly influenced their decisions about vaccination. Previous research has similarly shown that insufficient information hinders vaccine acceptance.6,7,14,16 Parents expressed a need for more comprehensive, culturally tailored education to make informed decisions. Addressing these knowledge gaps through clear, accessible information could improve vaccine acceptance. Some parents also expressed concerns about the vaccine’s safety, generally framed as uncertainty about potential risks rather than specific side effects, as well as worries related to its association with sexual health. These concerns align with findings from previous studies and suggest that educational campaigns clarifying vaccine safety could improve uptake.15,16,26,27,29,30
Family dynamics, particularly gender roles, played a significant role in vaccination decisions. Mothers were typically the primary decision-makers, a finding consistent with previous research, though spousal and extended family influences were also noted. While prior studies highlight the potential influence of social networks and peers on vaccination decisions, in our study most parents reported that their peers did not directly factor into their HPV vaccination decisions.7,16,26,27,29-31 These findings suggest that, although social networks can provide information or perspectives, parents in this sample relied primarily on family input and personal judgment when deciding about vaccination.
Healthcare providers were key influencers, with parents expressing trust in knowledgeable professionals. However, many noted limited communication and vaccine recommendations from healthcare providers, with time constraints during visits hindering effective counseling—a barrier identified in previous studies.27,29-31 To improve vaccination rates, healthcare providers should prioritize vaccine discussions, offering culturally relevant, personalized information, especially in immigrant communities where trust is essential. Allocating additional resources or counseling time could further enhance vaccine acceptance and allow for more in-depth discussions.42-45
Schools and health services were viewed as key sources of vaccination information, as they are trusted institutions within immigrant communities. However, parents reported mixed experiences regarding the clarity, accessibility, and adequacy of the information provided. Many found informational materials, especially pamphlets, to be unclear or lacking in essential details about the HPV vaccine, including its benefits and safety. This points to a broader issue highlighted in previous studies, which emphasize the need for communication that is not only clear but also culturally sensitive and linguistically appropriate to ensure that information resonates with the diverse needs of immigrant families.7,19,21 To address these gaps, schools and health services could consider interactive sessions to better address parents’ concerns. Additionally, community organizations—such as local centers or religious institutions—could play a critical role in bridging these gaps by distributing reliable health information.7,19,21
Cultural norms, including machismo and traditional gender roles, influenced attitudes toward HPV vaccination, often hindering open discussions about sexual health—a barrier identified in prior research.7,44,45 Health education tailored to these cultural values, especially when delivered through trusted community leaders or institutions, could improve vaccine uptake. Language barriers and misinformation also posed significant challenges, as many parents struggled to access accurate and culturally relevant information in their native language. Research highlights the importance of multilingual, culturally appropriate resources.7,44,45 Community-driven initiatives, such as health education through public health campaigns, local pharmacies, community centers, or informal conversation circles, could increase reach and overcome barriers to information access.7,8,22
Vaccination mandates were found to significantly increase vaccine uptake, aligning with research showing that school-entry mandates boost vaccination rates.46-49 However, some parents expressed resistance to potential future mandates, emphasizing the need for transparent communication about vaccine benefits and policies. Research suggests that mandates, while effective, can provoke resistance when parents lack understanding.46,47 Public health campaigns emphasizing the prevention of cancer and promoting the broader public health benefits of vaccines could help increase acceptance. Additionally, policies expanding healthcare access and funding culturally competent health education could further promote vaccination, as shown by previous research.20,28,44-46 Integrating health education into routine healthcare visits and expanding healthcare services in underserved areas could also enhance vaccine uptake and reduce disparities.
Limitations and Strengths
The findings of this study should be interpreted in consideration of several limitations. Selection bias may have influenced results, as purposive and snowball sampling could have overrepresented more engaged individuals with stronger opinions, limiting the diversity of views.36,50 Additionally, the context-specific nature of the study limits generalizability to other immigrant groups, given variations in cultural, socio-economic, and healthcare factors. 36
Social desirability bias may have affected self-reported behaviors, with participants potentially providing socially acceptable responses. 51 Although thematic analysis was used, theme interpretation is inherently subjective, and some researcher bias may have influenced the findings.37,51
The sample was drawn from Central American immigrant parents living in several U.S. states, but the majority of participants were from Massachusetts, primarily urban areas in Greater Boston, where research staff were based. Recruitment from other states (New Jersey, Illinois, North Carolina, New York, and Maryland) was limited, with only 1–4 participants from each, reflecting practical challenges of multi-state recruitment. 36 As a qualitative study, the sample was not intended to support state-level comparisons, and these limitations are inherent to the exploratory nature of the study.
Despite these limitations, the study’s strengths include semi-structured interviews that provided rich, in-depth insights into participants’ perspectives on HPV vaccination behaviors. The purposive and snowball sampling strategies enabled inclusion of a diverse participant group, including Central American immigrant fathers, who are often underrepresented in public health research. Overall, this study fills a gap by providing culturally relevant data to inform interventions aimed at improving HPV vaccine uptake among Central American immigrant families.
Conclusion
This study underscores that HPV vaccination decision-making among Central American immigrant parents from the Northern Triangle countries in the U.S. is influenced by a complex interplay of factors across multiple levels. Culturally relevant education, supportive communication from family, healthcare providers, and schools, community-driven initiatives, and policy-level interventions—such as mandates and public health campaigns—are all essential for improving vaccine uptake. These findings highlight that effective interventions must address these interconnected factors simultaneously. By applying a social-ecological approach, public health programs can more effectively promote HPV vaccine acceptance and coverage among Central American populations from El Salvador, Guatemala, and Honduras in the U.S.
Footnotes
Acknowledgements
We sincerely thank the parents who participated in this study for their valuable insights. We also appreciate the support from community members and organizations serving Central American immigrants, which was essential to the success of this research.
Ethical Considerations
The study protocol was reviewed and approved by the Institutional Review Board of the University of Massachusetts Boston (Protocol No. #30362022047; approval date: March 10, 2022). All procedures involving human participants were conducted in accordance with the ethical standards of the approving Institutional Review Board and with the Declaration of Helsinki of 1975, as revised in 2024.
Consent to Participate
Informed consent was obtained from all participants prior to their participation in the study.
Author Contributions
ACL and DLN contributed substantially to the conception of the work. DD, ACL, VAM, DL, AHN, and NRC participated on the acquisition of data for the work; dd, ACL, and DLN participated on the analysis interpretation; DD, ACL, and DLN participated in the drafting of the work. DD, ACL, and DLN reviewed it critically for important intellectual content. ACL acquired the funding for the research. All authors approved the final version to be published and agree to be responsible for all aspects of the work to ensure that issues related to the accuracy or completeness of any part of the work are adequately investigated and resolved.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme LLC (Ana Cristina Lindsay, Principal Investigator) MISP 60689. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC.
Declaration of Conflicting Interests
The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Data Availability Statement
Due to privacy and ethical restrictions, the data that support the findings of this analysis are not publicly available; however, they are available upon request from the corresponding author.