HPV Vaccination among KA and Koreans: Comparison
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Koreans and Korean Americans (KAs) have limited HPV knowledge and awareness.

  • Korean American
  • human papillomavirus
  • vaccination
  • Asian American

1. Introduction

Human papillomavirus (HPV) infection is the most prevalent sexually transmitted infection (STI) in the United States (US) [1]. HPV infection can lead to cervical, vulvar, anal, upper aerodigestive tract, oral, or skin cancer [2]. The cancer most impacted by vaccination, cervical cancer, had an estimated 14,480 new cases in 2021 in the US [3]. Considering the impact of preventing cancer, the vaccination rate is low. Less than half (43%) of females and about a third (31.5%) of males received the HPV vaccine, and this was much lower than other national vaccination programs (more than 88%) [4]. Moreover, research showed the ethnic variations in the vaccination rate: Asian Americans are the lowest HPV-vaccinated population [5]. The percentage of Asian American female young adults who received the vaccine was 22.8%, much lower than the rate for Caucasians (46.3%) [6].
Korean Americans (KAs) are the fifth-largest Asian American subgroup [7], and 1,887,914 were living in the US according to the 2017 US Census Bureau [8]. There is not enough information on the vaccination rate in regard to KAs. However, KAs are the second-most commonly diagnosed with cervical cancer among Asian Americans [9]. The literature has shown KAs had limited HPV awareness compared to Vietnamese and Filipino Americans [10] and limited HPV knowledge [11]. Most KAs do not even know that HPV is an STI [12], and 28% of KA students had never heard of HPV before [13]. Moreover, some KAs do not know HPV can cause cervical cancer [14], while some KAs are more familiar with the term ‘cervical cancer vaccine’ than HPV vaccine [13]. Even if they are aware of HPV, they think the vaccine is only for females [15]. In addition to limited knowledge, other barriers were found, such as healthcare providers not recommending the vaccine to KAs or KAs being worried about side effects, high cost, and not wanting to go to the women’s clinic [14,15,16][14][15][16]. However, little is known about what factors are associated with HPV vaccination behavior in KAs.
In general, immigrant populations are affected by the culture of their original country, especially the culture of their mother [17]. To increase the HPV vaccination rate among KAs, it is essential to investigate HPV knowledge, HPV awareness, and other associated factors, so that healthcare professionals can utilize these factors when they promote HPV vaccinations to these population groups. Foreign-born immigrants are less likely to receive the HPV vaccine than native-born Americans of the same ethnicity (i.e., second or later generations) [18]. Considering KAs inherit their health behavior culture from Korea, their HPV behaviors are similar to Koreans [15]. In Korea, the prevalence of HPV in the general population is estimated at about 20%, but more than 90% of cervical cancer cases are caused by HPV infection [19]. Similar to KAs, the research has reported limited HPV knowledge in Koreans [15,20,21][15][20][21]. More than 90% of Koreans did not know males could be infected by HPV [22]. Even though the HPV national program was started in 2016 for Korean female adolescents, only 67.4% have initiated receiving the first dose of the HPV vaccine [23]. The literature has shown concerns about the cost and adverse effects of the HPV vaccine, which are barriers preventing the receipt of the HPV vaccine among Koreans, as with KAs [21].

2. Low Levels of Knowledge and Awareness

The results showed were variable for HPV awareness. All the studies reported more awareness of the HPV vaccine than awareness of HPV itself. Awareness of the HPV vaccine was especially increased when the researchers asked about awareness of a cervical cancer vaccine rather than HPV or an HPV vaccine. This result is consistent with the results of an earlier study; 96.5% of women know about a cervical cancer vaccine, while only 52% of women had heard about HPV [35][24]. A possible explanation may be that the HPV vaccine was advertised as a cervical cancer vaccine at the time it was first licensed [36][25]. There was only one study that surveyed young adolescents who had actually received the vaccine. Only 1.71% of them were aware of HPV, which was remarkably low. This finding aligns with previous study results, though in a different population, that young adolescents have lower levels of awareness than older adolescents [37][26]. As the HPV vaccination is recommended from age 9, there should be education for adolescents about the vaccine.
In terms of HPV-related knowledge, all the studies reported limited HPV knowledge. The highest correct answer rate was 66.2% from school nursing teachers. It was not possible to compare with other studies that targeted other ethnicities, because each study used different measurements. However, the literature about other Asian Americans has also reported low levels of HPV-related awareness and knowledge in this population [10,38][10][27] and that they obtained information about HPV mostly from the media or family members, not from their healthcare providers [10]. This might be characteristic of immigrants as a population generally and applies to Korean Americans as well. The limited knowledge in KAs and Koreans from this study, in combination with the lower awareness shown, suggests the necessity of education from healthcare providers about HPV for KAs and Koreans.

3. Factors Associated with HPV Vaccination Intention Based on the HBM

The significant factors associated with HPV vaccination intention were young age, being female, higher education, higher income, occupational status, sexual intercourse experience, cervical cancer experiences, beliefs that their daughters need a pap smear, awareness of the HPV vaccine, HPV knowledge, recommendations from parents, perceived benefits, and perceived seriousness. The significance of young age, being female, higher education, higher income, and occupational status were the same as previous studies of Americans and immigrants in America [18]. It is assumed that people with higher education and higher incomes are more likely to have access to HPV information or the healthcare system, so they have a higher intention to vaccinate themselves or their children. One thing to consider is that mothers were more likely to vaccinate their daughters than fathers. Fathers of KAs were not aware of whether or not their children received the HPV vaccine, because mothers have a dominant role in caring for their children [15]. The significant association between HPV vaccination intention and gender might reflect these gender roles. Considering that parental recommendation for the HPV vaccination was an important result in this synthesis, education for fathers is needed as well. As HPV vaccine-related conversations are also linked to sexual topics, KA parents reported finding it challenging to start conversations with their children [15]. HPV infection causes cancers such as anal, upper aerodigestive tract, oral, or skin cancer not only in females but also in males [2]. Hence, sons, as well as daughters, can benefit from the HPV vaccine. A conversation between father and son might be culturally easier than a conversation between mother and son when discussing HPV and the HPV vaccine. Therefore, education that emphasizes HPV vaccination is also proposed to fathers, and as a result, fathers will be able to recommend and persuade their children to get the HPV vaccine.
Among the HPV-related factors, the synthesis of the results in terms of HPV knowledge was inconsistent. Only one study found a significant relationship between HPV knowledge and HPV vaccination behavior, while two studies found a nonsignificant relationship. HPV knowledge was measured using different measurement scales in each study. The inconsistent results might be a result of using different measurement scales. Using different measurement scales could lead studies to be noncomparable. There are some studies that have developed measurement scales of HPV knowledge using a standardized development process [39,40][28][29]. Since these predeveloped scales target certain types of age groups, future studies are recommended to use standardized measurement scales for the relevant population to enable comparisons of the results of a specific group with other studies.
HPV vaccine awareness was a significant factor for HPV vaccination intention, while the awareness of HPV itself was not a significant factor for HPV vaccination intention. A possible explanation may be that the HPV vaccine was advertised as a cervical cancer vaccine at the time it was first licensed [36][25]. Awareness of the HPV vaccine as a cervical cancer vaccine could prevent males from being vaccinated. In addition, even for females, cervical cancer is not the only cancer caused by HPV. Therefore, an educational campaign to promote knowledge of HPV itself, as well as its related cancers, is recommended.
Among the behavior-related factors, perceived benefits and perceived seriousness were significantly associated with HPV vaccination intention. In particular, all the studies that measured perceived benefits reported the significance of this variable’s relationship with HPV vaccine intention. Three studies targeted Koreans, analyzing high school or university students, school teachers, or mothers. This might imply Koreans will receive the HPV vaccine when they receive information about the benefits of the HPV vaccine. Additionally, the HPV vaccine was not yet free at the time the surveys were conducted, so the results of this study could emphasize the importance of providing information on the vaccine’s benefits. This could have an even greater relationship with vaccination now that the HPV vaccine is freely available to adolescent Korean women. One study conducted after the free national HPV vaccination program [32][30] reported a relationship with perceived benefits, but it did not use a multivariate analysis. Rather, they reported that awareness of the national HPV vaccination program was significantly associated with vaccination intention. Thus, future research to examine the relationship between perceived benefits and awareness of the national HPV vaccine program will allow healthcare providers to adjust the educational content when recommending HPV vaccines.

4. Quality Issues

While reviewing the results of the included studies, researchers found that some studies reported a discrepancy in results between the manuscript and tables. Where there was a discrepancy between the article itself and its tables, this study followed the results from the manuscript. Moreover, one article included incorrect information about their measurements. Future studies have to consider the quality of manuscripts by writing and reviewing articles more carefully.
In addition, studies about KAs did not clearly state their definition of KAs. Most studies indicated their inclusion criteria as being a self-identified KA or including both first- and second-generation KAs. There was no limitation for the years of living in the US or their age when they arrived in the US as inclusion criteria. Immigrant generation can be classified in various methodologies such as age at arrival in the US, nativity, or parents’ ethnicity [17]. Moreover, as parental recommendation is more important in the KA population than the recommendation of doctors, the second generation might have different behaviors than the first generation. Thus, future studies for KAs need to apply strict acculturation inclusion criteria and report the results by each generation in order to account for differences among the subgroups of KAs.

5. Implications

HPV vaccination is the primary preventive measure against HPV infection and its development into cancers. However, racial disparities among HPV vaccination have been reported [6]. While the previous literature has discovered HPV knowledge influences HPV vaccination and HPV infection in American women [41][31], there is no clear relationship between HPV knowledge and HPV vaccination intention among Koreans and KAs. On the other hand, the perceived benefits of HPV vaccination were a consistently significant factor among Koreans and KAs. Therefore, campaigns on changing the paradigm from discussions of cervical cancer to various HPV-caused cancers, in addition to providing information on the benefits of the vaccine, are suggested at the national level for Koreans. In terms of KAs, the results suggest involving both fathers and mothers in recommending the HPV vaccine to their children, so both parents can persuade sons, as well as daughters, to receive the vaccination against HPV.

6. Limitations

The major limitation of this study is the analysis of KAs and Koreans as a whole. The reason researchers did not exclude either group is that it is likely first-generation immigrants are affected by their original culture and have the unique health-related beliefs of that culture [18]. Further, there were not enough quantitative studies about KAs. In addition, this study did not synthesize the results from the qualitative studies. The five qualitative studies included in this study reported results about HPV vaccine acceptance behavior. However, those results were not comparable, since some studies reported neutral information or results from different points of view in a way that prevented direct comparisons. Comparatively, the results from quantitative studies were able to be synthesized, since they provided statistical results. Considering most studies that targeted KAs were using a qualitative design, future studies using a quantitative design are recommended for research about KAs.
Another limitation in the studies about Koreans was that all the studies except one were conducted before the HPV vaccine became free to female adolescents as one of the national vaccination programs in 2016. The vaccine for male adolescents in Korea is not complementary. Therefore, future studies are recommended to examine the attitudes regarding the HPV vaccine and HPV knowledge and see how these have been changed in comparison to the previous studies, as well as how they may differ by sex.

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