1. BY: Christina M. Lattner DNP, APRN, AGNP-C, ANP-BC
Impact of HPV Education on Knowledge, Perception, and Cultural influence among African American Parents A Graduate Research Project Presented in Partial Fulfilment of the Requirements for the Degree of Doctor of Nursing Practice June 2017
BY: Christina M. Lattner DNP, APRN, AGNP-C, ANP-BC
DePaul University
Chicago, Illinois

2. Panel Information Dr. Young- Me Lee PhD, RN DNP Committee Chair
Christina Lattner MSN Ed., AGNP-C, ANP-BC
Dr. Linda Graf DNP, CNM, WHNP-C, APN, RN Doctoral Candidate
DNP Committee
Dr. Joseph Tariman PhD, RN, ANP-BC, FAAN

3. Why I Pursued this Project
Strong belief in patient education
Interest in learning about cultural barriers that prevent African American’s from seeking care and trusting healthcare facilities.
Personal belief that the answer to increasing HPV vaccine uptake rates resides in the Advance Practice Nurse.
I am drawn to the medically underserved population.
1. In my opinion patients’ decisions are often based on their knowledge and the time we make to discuss their fears and expectations in health care.
2. Most research on interpersonal trust with healthcare has focused on Caucasian patients, however views of the trustworthiness of health care differs for African Americans. AA’s are faced with Historical legacy of mistreatment…examples such as the Tuskegee syphilis experiment, The immoral life of Henrietta Lacks, and current health disparities altogether.
Multiple studies also indicate that distrust often leds them to forgo care and or not seeking it in the first place. In order to reach this community, we have to consider their cultural influence period.
3. Primarily there are issues with the comfort level of pediatric providers discussing sexual behavior of young children with parents. This discomfort talking about sex appears to be a more salient factor than safety or other concerns about HPV vaccine.
Having more FNP as advocates for the HPV can increase vaccination updates as we work on a more holistic model/approach than pediatricians.
4. Underserved populations are less likely to receive recommended preventive measures and screening and have poorer outcomes for chronic illnesses. This is not just their problem but all our problem.

4. Background and Significance
Human papillomavirus (HPV) is the most prevalent of all sexually transmitted infections. Reports indicate nearly 80 million people are currently infected in the U.S. (CDC, 2016).
Vaccine is available since late Vaccination rates for HPV in the United States remains low; especially in the African American community.
Current vaccination rates for African American adolescent girls and boys is 42% vs. the national average of 63% Hispanic and 65% Caucasian adolescents

5. Problem Statement
Despite research on cervical cancer and CDC recommendations, HPV vaccination remains voluntary. To eliminate HPV-related cancers through vaccination, it is essential to recognize the factors involved in the knowledge, perception and cultural barriers related to HPV in African American parents.
1. African-American women are diagnosed with cervical cancer at a later stage than other ethnic groups.
makes the cancer difficult to treat along with the higher mortality rates.
2. Since states and territories have introduced legislation to require the vaccine, fund or educate the public or school children about the HPV Vaccine., however February 2, 2007, Texas became the first state to enact a mandate-by executive order from the governor-that all females entering the sixth grade receive the vaccine, with some exceptions.

6. Purpose The purpose of this project was to assess:
The knowledge and perception of African American parents regarding HPV and the HPV vaccine.
Examine the effectiveness of an HPV education program developed for African-American parents to increase knowledge, improve perception, and acknowledge cultural influences.
Examine the acceptability of the created HPV education program specifically for this target population.

7. Research Questions
How do cultural influences affect the decision of African-American parents to vaccinate their children and what is the level of comfort in discussing HPV and the HPV vaccine with providers.
What is the difference in HPV knowledge and perception before and after implementation of the HPV education program in African- American parents?
What is the parents self-reported informed decision regarding the HPV vaccine for their children after HPV education program?
What is the level of acceptability and satisfaction with the tailored HPV education for African-American parents?

8. Conceptual Framework Health Belief Model
Figure 1. Application of Health Belief Model in this study
The Health Belief Model is an evidence based framework for motivating people to take positive health actions.
Framework uses the desire to avoid a negative health consequence as the key element and prime motivator for understanding and changing health behavior. (Champion & Skinner, 2008).

9. Review of Literature
A detailed search of literature was performed to first to note “what are barriers that effect initial HPV vaccination and vaccination completion in African American adolescents”.
Overarching themes noted lack of knowledge regarding HPV risk , African American cultural issues and parental barriers.
Interesting finding:
Cultural issues regarding mistrust of healthcare and providers.
Overall conclusion of the literature review:
Lack of knowledge in HPV and the HPV vaccine is a solecism in provider practice.
Breach in our responsibility to improve patient outcomes.
1. This lead to discovery that there are several factors that come into play.
 2. Parents were cited as having a lack of knowledge to HPV as a STI, Lack of knowledge regarding the availability of the vaccine, denial of children sexual activity, and overall comfort of discussing HPV and sexual activity with children.
3. Many authors stated, African Americans have general distrust in healthcare partly in response to historical inequities of care and out right instances of mistreatment.
While I have always known this, the literature review offered a deeper insight into how cultural influence plays a large factor in how AA parents practice accessing medical care.
Clinical studies regarding this population must continue to explore the extent to which multidimensional factors such as socioeconomic status, cultural beliefs, behavior, and biological variations contribute to the unequal health status of African Americans and their choice to participate in preventative medicine.
4. A study I reviewed stated 77% of African American stated they are likely vaccinate if education were made available and 88% stated they depend on their provider to recommend what is needed to help protect their child.

10. Methods Measurements Research Design
A descriptive, single-group pre-test post- test design
Sample
Community based convenience sample of 102 African American parents and children.
Inclusion Criteria 1) African American parents ages 21 to 50; mothers or fathers. 2) Adolescent children male or female between the ages of 9 to 18 years of age.
Measurements
HPV Knowledge (6 questions)
Cultural Influence (3 questions)
Comfort in discussing HPV with health care provider (3 questions)
HPV and HPV vaccine perception (7 questions)
Parental report of intent to vaccinate their child (1 questions)
Was not easy to gather 102 participants between IRB approval in November and Data processing in January…spent my holiday time as a party scavenger! Where ever there was, a gathering I was there!!!!!

11. Methods Data Analysis Collection Method
Self-reported decision to vaccinate
Pre-testing
Tailored HPV Education Program
Post-Testing
HPV Satisfaction Survey
Collection Method
Data Analysis
Collected and analyzed using the Statistical Package for the Social Sciences, v22 (SPSS, Inc., Chicago IL).
Percentages, frequency table for categorical variables, descriptive statistics and paired t test were all used.
All pre-testing, post-testing and HPV educational program were administered face to face.
As opposed to survey’s, survey monkey or other tools. I wanted to be present to thoroughly provide education regarding HPV to each and every participant.

12. HPV Education Program
Most materials found on HPV provide basic information yet, they were limited with providing in-depth information that is individualized to African American’s with specific regards to cultural and educational needs.
My created HPVEP was developed with regards to specific cultural needs and focused on the perceived barriers, perceived uncertainty’s in cost, insurance and perceived susceptibility, as AA parents struggle with sex and their adolescent children.
In addition to cultural specific information targeting the statistical rates of HPV and cervical cancer diagnosis and mortality in African American women.

13. Demographics Description of Sample
Mean age of African American Parents 35 years (SD=.286)
91% Female, 8.9% Male
Mean age of Children 12 years (SD=2.46)
67% Girls, 34% Boys

14. Findings…Knowledge
Participants answered “true”, “false “and “unsure.” Total number of correct answers were scored.
Correct answers ranged between 1 and 5; higher number indicates a higher level of knowledge; lower number implied less knowledge.
The mean score for correct answers pre- testing was 1.29 (SD= 1.03), indicating lower knowledge base.
Post-testing the mean was (SD=.345), indicating an improvement in knowledge after the HPV educational program.
Knowledge Item
% Correct response Pre-Testing
% Correct response Post-Testing
You have heard of HPV?
23.5%
100%
Only adult women can get HPV? 0%
86.3%
HPV infections can cause Genital Herpes which leads to Cervical Cancer?
35.3%
Pap Smear testing may indicate infection of HPV or presence of Cervical Cancer cells?
59.8%
HPV is a common Sexually Transmitted Infection?
10.8%
Five questions were asked regarding knowledge.

15. Findings…Culture Impact of Culture on the HPV Vaccination
Three specific questions regarding the impact of culture on healthcare and the HPV vaccine. Participants answered not at all , very little , some , or very much.
The mean reported was 7.42 (SD= 1.43), indicating that culture has a great impact on healthcare decision.

16. Findings…Provider Influence
Knowledge Variables
Uncomfortable
% (N)
Comfortable
Very Comfortable
Are you comfortable with your provider helping you discuss HPV and the HPV vaccine with your child?
2.9% (n=3)
63.7%
(n= 65)
33.3 (n=34)
Do you feel comfortable discussing HPV and the vaccine with your health care provider?
62.7%
(n= 64)
32.4% (n=33)
Do you feel comfortable discussing HPV and the HPV vaccine with your child?
59.8% (n=61)
40.2%
(n= 41)
n/a
Three specific questions regarding level of comfort. Participants answered very uncomfortable, uncomfortable, comfortable or very comfortable
97% (n=99) of participants either stated they were comfortable or very comfortable in having the provider discuss HPV infections and the HPV vaccine with themselves and their children
Indicate parents are comfortable allowing the conversation to take place with provider assistance.

17. Findings…HPV Perception
Perceived Susceptibility
Too young for HPV vaccine
More likely to have sex if given.
Safety of vaccine; too new; I never had it.
Perceived Benefits (Effectiveness)
Does it work in preventing cervical cancer and genital warts?
Perceived Uncertainty
Cost of vaccine; does insurance pay?
I don’t know enough about it.
Perceived Barrier
Can I get it at my medical office ?
Why do I need to go back 3 times?
Perceived susceptibility - Agree Strongly, Agree Slightly, Disagree and Disagree Strongly. Score ranged from 2 to 8, lower the score the more susceptibility is involved. Perceived benefit- Strongly Effective, Slightly Effective, and Non-Effective. Score ranged from 1 to 3, lower the score, indicated a less perceived benefit of HPV vaccine to prevent HPV related cancer Perceived uncertainty- Agree Strongly, Agree Slightly, Disagree and Disagree Strongly, concerning cost and lack of information regarding HPV vaccine. Score ranges from 2 to 8, Lower the score, more uncertainty. Perceived barrier- Very Hard, Slightly Hard, Slightly Easy and Very Easy to these items. Total score ranges from 2 to 8, where the lower the score, the larger the perceived barrier.
Perceived susceptibility low - Agree Strongly, primarily Too young for HPV vaccine. More likely to have sex if given. Safety of vaccine; too new; I never had it. Severity of HPV is overlooked.
Perceived benefit low - Non-Effective. primarily does it really prevent Cervical CA or genital warts. This was a normal response as Knowledge regarding the vaccine was low
Perceived uncertainty high- Agree Strongly, primarily with uncertainty regarding cost, vaccine must be expensive and limited knowledge of why it is needed.
Perceived barrier high- Very Hard, primarily with barrier of it not being available where they currently receive medical care, and if it takes 3 visits it is a hassle.

18. HPV Perception Knowledge Item Pre-Testing Mean & Standard Deviation
Post- Testing Mean & Standard Deviation
Perceived Susceptibility
Mean 1.80 (SD=1.57)
Mean 6.95 (SD=0.60)
Perceived Benefit
Mean 1.39 (SD=.490)
Mean 2.55 (SD=.606)
Perceived Barrier
Mean 2.77 (SD=1.06)
Mean 3.90 (SD=.433)
Perceived Uncertainty
Mean 3.41 (SD=1.47)
Mean 6.06 (SD=.786)

19. Findings…Impact of HPV Education Program on Knowledge and Perception
Paired t-test were used to determine differences in knowledge and perception before and after the implemented HPV education program.
HPV knowledge and perception were found Significant differences in mean score before and after HPV education.
Pre-perception regarding the availability, effectiveness and cost of the HPV vaccine ranged between a minimum of 9 and maximum 21. Scores of 14 less show inaccurate perception. Post-testing, scores of 15 or greater indicated acquired accurate perception.
Pre-knowledge of HPV and the HPV vaccine ranged between a minimum of 7 and maximum 15. Scores of 10 or greater indicated limited knowledge of HPV and the HPV vaccine. Post-testing, scores of 6 or less indicated gained knowledge.
Responses indicate many participants had limited knowledge and inaccurate perceptions pre-testing.

20. Findings…Self-Reported Decision
Findings…Self-Reported Decision
Knowledge Variables
Yes
% (N) No
Unsure
Do you think you will make the decision to allow your child to get the HPV vaccine based on your current knowledge about the infection?
(Pre-test)
0% (n=0)
72.5% (n= 74)
27.5% (n=28)
Do you think you will make the decision to allow your child to get the HPV vaccine based on your NEW knowledge about the infection?
(Post-test)
79.4% n=81)
11.8% (n=12)
8.8% (n=9)
Asked in the pre-test and post- test
Formatted statement, answered with yes, no or unsure.
72.5% (n=74) responded “no” in the pre-test based on current knowledge.
79.4% (n=81) responded “yes” in the post-test based on gained knowledge from HPV Education Program.
The majority responded with ‘no’ initially, provided education increased knowledge and perception in parents with 79% self-reporting “yes” to the vaccine after intervention.

21. Satisfaction of the HPV Education Program
Total of 10 questions, Participants could score a range between 1 and 5. The higher the score, higher satisfaction. Overall satisfaction, Mean 4.43 (SD=
Three specific to “intent to vaccinate” and “understanding HPV and the HPV vaccine”.
63.7% (n=65) participants agreed and 36.3% (n=37) strongly agreed that the HPV education program helped them understand HPV and the HPV vaccine.
90.2% (n=92) strongly agreed that the HPV education program gave strong reasons why a child should be vaccinated.
78.4% (n= 80) strongly agreed that the educational program motivated them to request the HPV vaccine for their child.
As highlighted in yellow, there were three specific questions asked regarding if the education program helped explain HPV, the HPV vaccine and if the education program gave strong reasons why a parent should vaccinate their child.
The numbers were outstanding, indicating with appropriate education vaccination rates can increase in this population.

22. Significance of Findings
Discussion
Significance of Findings
Limitations
Contributes to the body of literature, regarding low knowledge of HPV and the HPV vaccine.
Prevention strategies directed at African American are urgently needed to reduce marked and persistent health disparity. (Cervical CA & HPV infections)
78% of parents have not had the vaccine offered at a primary visit.
Perception susceptibility suggests a need for more education on the severity of HPV.
Cultural influence dictates decisions in African American’s; 48% stated and 66% have mistrust.
Small convenience sample of 102.
Self-reported decision to vaccinate, not enough.
Unable to fully explore cultural influence and provider comfort.
Lower Cronbach Alpha for knowledge and perception.
Significance of Findings:
1. Knowledge and perception of the HPV and the vaccine was disturbingly low in pre-testing.
2. HPV prevalence is observed among low-income and minority populations; particularly African American adolescents relative to other ethnic/racial groups.
3. Education to increase the knowledge of HPV is missing. Vaccine has been out since 2006, yet I am just now seeing television commercials.
4. researchers have extensively studied parents' and adults' willingness to receive the HPV vaccine and have their children vaccinated. However, little has been done to understand HPV vaccine acceptance to participants of diverse cultures. Education is not a one size fits all…as providers we must know our audience.
Limitation:
1. Small convenience sample, can cause sampling bias or note that the sample is not representative of the entire population.
2. Especially when dealing with the severity of HPV, actual vaccination could be a better outcome measure.
3.Knowledge pre .364 post .388 perception pre .424 post .168

23. Direction for Future Studies
Discussion
Direction for Future Studies
Nursing Implications
Examine the effectiveness of an educational program intervention using actual vaccination behavior as the outcome measure.
Expand research to pediatric practices to determine the comfort level of pediatric providers.
More qualitative study needed to understand cultural influence.
Advance practice nurses are a key source of both information and advice regarding HPV infection, vaccination and testing.
Utilize FNP’s to cover pediatrician gaps.
1. Intention to vaccinate their children after intervention of the educational program was studied rather than actual vaccination behavior.
In future research the effectiveness of an educational program intervention using actual vaccination behavior as the outcome.
2. Literature suggests that some providers, especially pediatricians, find the interpersonal environment to be challenging when it comes to talking about HPV vaccination. Related to the discussion of sexual activity
Nursing Implications:
1. APN’s traditionally spend more time and by nature offer more education. This project can note the improvement of knowledge and perception of HPV and the HPV vaccine in parents with the implementation of education by providers.

24. Conclusions
There is a significant lack of knowledge and inaccurate perceptions of the HPV virus and HPV vaccine in African American parents. Parents attitudes and perceptions toward the HPV vaccine were positive after educational intervention, indicating cultural barriers can be lifted in this population
There is a great need for development of a cultural based educational program to increase African American parents’ knowledge and vaccine perception in order to improved safety and increase uptake of the HPV vaccination in African American adolescents.