Introduction

Human papillomavirus (HPV) vaccines are safe and effective in preventing HPV infection and HPV-related cancers such as cervical cancer [1]. According to the Centre for Disease Control and Prevention [2], HPV infection rates have decreased by 88%, and cervical precancer rates have decreased by 40% since HPV vaccines were licensed for use in 2006. The primary target population to receive HPV vaccination is girls aged 9 to 14 years who are not sexually active, and the secondary target population, which should be vaccinated when the resources are available and affordable, is women aged 15 years and older [1]. Targeting multiple age cohorts aged between 9 to 18 years could lead to a greater impact, as more protection and herd immunity could be achieved [1]. In 2019, at least 100 countries included HPV vaccines in their national immunisation or vaccination programme [1]. The United States (US) National Immune Survey in 2020 reported that 75.1% of adolescents aged 13 to 17 years from different ethnic groups had received at least one dose of the HPV vaccine [3]. In Australia, 80.2% of 15-year-old girls had completed a three-dose HPV vaccine series [4]. Although HPV vaccine uptake is high, a systematic review and meta-analysis of studies conducted in the US found that the HPV vaccination series completion rate was 8.6% lower in the ethnic minority population than in the majority population [5].

Vaccine uptake could be affected by multiple factors, and studies have shown that ethnic minority populations may face more barriers to accessing health services than majority populations [6, 7]. In addition, parents’ decisions to vaccinate their adolescent daughters is one of the important factors influencing HPV vaccine uptake [8, 9]. Thus, understanding parents’ perspectives is also essential for identifying the factors influencing their decision. A systematic review and meta-analysis conducted by Newman et al. [9] revealed that receiving a recommendation from a physician, belief in vaccines and perceived benefits of the HPV vaccine were major factors positively associated with the parents’ uptake of the HPV vaccine for their daughters, and concerns about HPV vaccine safety and out-of-pocket cost were major factors that had negative effects on HPV vaccine uptake. Amboree and Darkoh [8] conducted a systematic review to investigate the barriers to HPV vaccination encountered by racial/ethnic minorities in the US. In addition to a lack of provider recommendation and safety concerns, inadequate knowledge and awareness of HPV and vaccination, religious and cultural beliefs and medical mistrust were common factors associated with low HPV vaccination initiation and completion among these groups [8].

HPV vaccines have been registered for use in Hong Kong since 2006. Since 2019, the HPV vaccine has been included in the Hong Kong Children Immunisation Programme to cover vaccination against HPV for eligible female primary school students of suitable ages (around 9–12 years old) [10]. Television advertisements, posters on public transport, leaflets placed in clinics and social media posts in English and Chinese are common promotional strategies used to encourage eligible Hong Kong citizens to receive the HPV vaccine [10]. Several studies have explored the factors influencing parents’ decisions to vaccinate their adolescent daughters against HPV [11, 12]. Yuen et al. [12] conducted a school-based HPV vaccination programme to enhance HPV vaccine uptake among Hong Kong Chinese students aged 9 to 14 years in primary and secondary schools. The study findings showed that 80.8% of the recruited students completed two doses. Parents’ preference for their daughters to receive the vaccine at school was a significant positive factor associated with vaccine uptake, and the perception that the HPV vaccine could protect their daughter from develo** cervical cancer and vaccine recommendation from a doctor were factors facilitating parents’ decisions to allow their daughter to join the vaccination programme [12]. However, for those parents who did not know about the HPV vaccine and were willing to pay for the vaccine themselves, the preference to have their daughter receive the vaccine at a private clinic was associated with lower uptake [12].

South Asians are one of the major ethnic minority groups living in countries such as the US, the UK, and Hong Kong. In Hong Kong, the majority population are Chinese and 8% of the population is composed of ethnic minorities, and South Asians (Indian, Pakistani and Nepalese in this study) form one of the largest ethnic minority groups [13]. Local studies have shown that South Asians experience multiple barriers to accessing screening services, such as lack of knowledge, language barriers, culture-related barriers and personal health beliefs [6, 14, 15]. Screening uptake among South Asians is also generally lower than that in the majority Chinese population [16]. However, few studies have explored the factors influencing South Asian mothers’ decisions to vaccinate their daughters against HPV. The comparison of the factors influencing HPV vaccination decisions among South Asian and Chinese mothers could further improve our understanding of the distinct needs of South Asian minorities. We aimed to explore the barriers and facilitators affecting South Asian and Chinese mothers’ decisions to have their daughters vaccinated against HPV and examine the differences between South Asian and Chinese groups.

Methods

Study Design

A prospective qualitative exploratory study was conducted to investigate participants’ perceptions of HPV vaccination and determine how HPV vaccine uptake could be increased. The report of the study follows the Standards for Reporting Qualitative Research (SRQR) [17].

Participants

The criteria for participants to be included in this study were as follows: 1) South Asian (Indian, Pakistani or Nepalese) or Chinese mothers aged 18 or older; 2) having at least one daughter aged 9 to 17 years; and 3) ability to understand Cantonese, English, Hindi, Urdu, or Nepali. A purposive sampling approach was used, and we recruited participants from community centres or non-governmental organisations that provide support services for mothers of adolescents. We aimed to include participants with a variety of median monthly household incomes and education levels, as these factors might affect mothers’ perception of the HPV vaccination and their decision to vaccinate their daughters.

Data Collection Procedure

Ethical approval was obtained from the ethics committee of the investigators’ institution (Reference No. SBRE-20–754). Focus group interviews were conducted after an information sheet with study details was provided, and written consent was obtained from the participants. A focus group interview was used because this approach can enhance the dynamics and interactions between participants and enable the generation of rich data. A semi-structured interview guide was developed based on the literature and Health Belief Model (Rosenstock, 1974). The model states that a person’s behaviour is influenced by their perceived susceptibility to the disease, the severity of the disease, barriers to and benefits of executing the preventive behaviour as well as cues-to-action from internal and external sources. Modifying factors, such as knowledge of the disease and preventive measures, also have a significant effect on the target health behaviour [18]. During the interview, open-ended questions were used to encourage participants to discuss and express their views (Table 1). Prompts were made as appropriate to obtain more in-depth information or content clarification. Each focus group interview was conducted by the investigator(s), supported by trained South Asian interpreters who helped in onsite interpretation in the language preferred by the participants. The interviews were conducted either face-to-face or via Zoom. Data were collected from May to September 2021. Twenty-two focus group interviews were completed. The interview lengths ranged from 60 to 90 min and the interviews were audio-recorded with participants’ consent. After the interviews were completed, HK$100 was provided for participants as a token of appreciation.

Table 1 Focus group interview questions with respect to the HBM constructs
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Data Analysis

The focus group interviews were transcribed verbatim by trained bilingual translators. The transcripts were then validated by other groups of bilingual checkers to ensure that the dialogue and responses transcribed in English were consistent with the original language used by the participants. Content analysis was conducted to identify and understand the barriers and facilitators influencing mothers’ decisions to vaccinate their daughters against HPV. Content analysis is a technique to objectively and systematically describe the manifest or latent content of dialogue. It facilitates making valid inferences from written data to describe a specific situation or experience [19]. Content analysis has four main stages as described by Bengtsson [19]: decontextualisation, recontextualisation, categorisation, and compilation. First, meaning units are identified from the text and labelled with codes. Second, the text is read together with the list of meaning units (codes) to ensure that all aspects of the content that could answer the research question are covered. Third, the meaning units (codes) are brought together to identify homogenous groups that represent contextual meaning. In this categorisation stage, the barriers and facilitators are depicted according to Health Belief Model constructs. In the final compilation stage, realistic conclusions are drawn through the presentation of a summary of themes, theme categories and subcategories are created, and appropriate examples of quotes are used to support the analysis process. To ensure that the results were logical and reasonable, a final check was performed by a colleague who was not involved in the study [19]. Rigour and trustworthiness were enhanced following the guideline established by Linoln and Guba [20], which includes credibility, dependability, confirmability and transferability. Credibility was achieved by peer debriefing. Dependability and confirmability were achieved by maintaining audit trails, including coding decisions and analysis and presentation of data. Transferability was achieved by providing the details of the study context, process and findings.

Results

A total of 73 South Asian mothers (22 Indian, 24 Pakistani, and 27 Nepalese) and 12 Chinese mothers agreed to participate in the study. Among the South Asian participants, most of the Indian mothers (72.7%) had received tertiary education, around 77% of the Nepalese mothers received secondary education or above. More than 50% of the Indian and Nepalese mothers had median monthly household incomes of HKD 20,001 or above, and only 20.8% of the Pakistani mothers were in this income bracket. Most Chinese mothers (75%) received tertiary education. More than 90% of the Chinese mothers had a median monthly household income of HKD 20,001 or above (Table 2). The interview results were organised to present the barriers and facilitators affecting HPV vaccination decision-making by South Asian and Chinese mothers, respectively. The barriers and facilitators were described using Health Belief Model constructs.

Table 2 Participants characteristics (N = 85)
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Barriers Hindering South Asian Mothers’ Decisions to Vaccinate Their Daughters

Four categories were derived to describe the barriers hindering South Asian mothers’ decisions to vaccinate their daughters against HPV: 1) inadequate awareness and knowledge of cervical cancer, HPV and the HPV vaccine; 2) low perceived susceptibility to HPV and low perceived need for vaccination; 3) high perceived barriers to HPV vaccination due to vaccine safety- and cost-related issues and language; and 4) influences from internal and external sources.

Inadequate Awareness and Knowledge of Cervical Cancer, HPV, and the HPV Vaccine

According to South Asian mothers, inadequate awareness and knowledge of HPV and the HPV vaccine significantly influenced their decisions to vaccinate their daughters. Some mothers expressed that this was their first time hearing the terms “cervical cancer”, “human papillomavirus”, or “HPV vaccine”.

We just heard about this. We did not know that we can get a vaccination for this disease [cervical cancer]. (Pakistani mother, P09)

Low Perceived Susceptibility to HPV and Need for Vaccination

According to the mothers, they believed that daughters’ age and presence of sexual activity had associations with their daughter’s susceptibility to HPV. South Asian mothers, especially Indian and Pakistani mothers, believed that their daughters would remain sexually inactive before marriage.

In Indian culture, or you can say other Asian countries as well, the kids themselves know when they can be more sexually active. Most commonly after marriage, I should say. (Indian mother, I02)

The perceived need for their daughters to get vaccinated was closely related to the perceived HPV susceptibility. Indian and Nepalese mothers thought that it was better to receive this vaccine at an older age or when their daughters had boyfriends. Pakistani mothers thought that it was better to receive this vaccine just before or after marriage.

It is ok for the girls to [wait to] get this vaccination until 18 years old if they are not married…I mean, if they don’t have any sexual life. (Pakistani mother, P06)

High Perceived Barriers to HPV Vaccination

The safety, side effects, and cost of the vaccine and language barriers to arranging the HPV vaccination were commonly perceived barriers reported by South Asian mothers.

Concerns About the Safety and Side Effects of the HPV Vaccine

Nearly all South Asian mothers were concerned about the side effects of the HPV vaccine, including whether it would affect their daughters’ development during puberty, trigger irregular menses or cause infertility.

I do have a concern. As my daughter is 11 years old, will the vaccination have any effects on her puberty, like any delays in development? (Indian mother, I01)

Concerns About the Cost

The HPV vaccine has been included in the Hong Kong Childhood Immunisation Programme since 2019, and girls in primary five and six (around 9–12 years old) could voluntarily receive two doses of the HPV vaccine for free. Other girls who could not benefit from this programme would have to pay to obtain the HPV vaccination at a private clinic.

It’s so expensive. Is there any financial sponsorship from government?’ (Pakistani mother, P12)

Language Barriers

Most South Asian mothers encountered language barriers that limited their ability to access healthcare services. Most Indian mothers expressed that they could communicate in English, but still had difficulties when they encountered staff who spoke only Cantonese. Most Pakistani and Nepalese mothers had a fair grasp of English but needed to arrange interpretation services or have their husband or a friend accompany them to medical consultations.

I cannot speak, and I ask for service from the doctor, but they don’t provide an interpreter for me. My husband doesn’t get day[s] off, or I cannot find friends [to interpret for me]. (Nepalese mother, N19)

Influences from Internal and External Sources

Most South Asian mothers relied on advice and support from healthcare professionals and their families to make the HPV vaccination decision for their daughters. Their religious and cultural teachings also affected their beliefs and the discussion of health topics with others.

Absence of Healthcare Professionals’ Recommendation for HPV Vaccination

All South Asian mothers believed that information, including about the HPV vaccine, received from healthcare professionals was reliable. Despite this, all mothers revealed that their healthcare professionals did not discuss or recommend this for their daughters.

Yes, we trust the doctors. They cannot give any false advice because vaccines are given under the government’s control. So, of course, we trust them. But, no, I haven't received any information from the doctors that I visited. (Indian mother, I02)

Family Support

The decision for daughters to receive the HPV vaccine was often a joint decision between the father and mother. South Asian mothers expressed that support from family members played a significant role in their decision to vaccinate their daughter, although they had the autonomy to make the final decision.

I will discuss [the decision to vaccinate] with my daughter and husband. Father and mother both make the decision on these matters. We discuss it together. (Nepalese mother, N26)

Pakistani mothers, in particular, expressed that their husbands’ agreement was very important. They agreed that they should ask for their husband’s opinion first and obtain their consent. The father’s opinion on child-related matters was considered important, and if the fathers did not agree, the mothers would follow their decision.

We both decide together. If my husband doesn’t agree, I cannot go against my husband. So, his decision is the same as my decision. (Pakistani mother, P15)

Religious Teachings on Lifestyles

All South Asian mothers said that their religion did not pose any restrictions on medical issues such as vaccination practices. However, some South Asian mothers who were Muslim revealed that religion did restrict other aspects of their lifestyles, including wearing clothing covering the whole body and staying at home. They followed the Muslim teaching to not engage in any sexual activity before marriage. This affected Muslim mothers’ perception of whether their daughters need to receive the HPV vaccine.

Because we are Muslims, so we are not going to worry about this one (sexual activity) … we are worried about their diet, exercise, not properly slee**, taking rest. So, usually, these are the factors we are worried about. (Pakistani mother, P02)

Cultural Teachings About the Discussion of Health Issues

South Asian mothers were conservative in requesting information or discussing health topics with doctors. Some mothers expressed that it was inappropriate to discuss cancer in public area.

I don’t think anybody will go on their own to discuss cancer. (Indian mother, I11)

No, I feel scared to ask such things (cervical cancer and HPV vaccine information). (Nepalese mother, N01)

Facilitators Enhancing South Asian Mothers’ Decisions to Vaccinate Their Daughters

Three categories were derived to describe the facilitators enhancing South Asian mothers’ decisions to vaccinate their daughters against HPV: 1) positive influences and support from external sources, 2) high perceived benefit of HPV vaccination, and 3) high perceived severity of cervical cancer and HPV infection.

Positive Influences and Support from External Sources

Receiving HPV vaccine information from reliable sources, the availability of subsidies for HPV vaccination and vaccination programmes arranged by schools and government could positively reinforce South Asian mothers’ decisions to vaccinate their daughters against HPV.

HPV Vaccine Information from Reliable Sources

Among those South Asian mothers who were aware of the HPV vaccine, some had received vaccine-related information from their daughters’ schoolteachers and some mothers obtained information from health talks organised by non-governmental organisations. South Asian mothers believed that healthcare professionals and schoolteachers would not give false information.

Yes, we trust the doctors. They cannot give any false advice because vaccines are given under the government’s control. So, of course, we trust them. (Indian mother, I02)

All kids go to school, and we all trust the school as the source of any information. (Indian mother, I05)

Availability of Subsidies for HPV Vaccination

As most South Asian mothers expressed that there were financial constraints in their families, the provision of free vaccines or subsidies from the government for the HPV vaccine could positively influence South Asian mothers’ decisions to get their daughters vaccinated.

It would be good if middle- and low-income families can get subsidies from the government. Because if the cost is high, we cannot afford it. (Nepalese mother, N13)

Availability of HPV Vaccination Programmes Arranged by Schools and the Government

Most South Asian mothers agreed that the availability of HPV vaccination programmes arranged by schools and the government would positively influence their decision to vaccinate their daughters. Such an arrangement could also help to overcome and avoid some of the mothers’ barriers, such as knowledge deficits in relation to the disease, and language barriers during service arrangement.

If they can provide information about where, the places or centres where our daughters can receive the second dose of [the HPV] vaccine, this will be much easier if the school or government will tell us where to go. (Nepalese mother, N02)

High Perceived Benefit of HPV Vaccination

South Asian mothers felt relief when they knew about the protections offered by HPV vaccine against HPV infection and prevent suffering from cervical cancer. Although they mentioned they were concerned about the side effects of the vaccine, they felt the benefits of the vaccine would outweigh the potential side effects.

If she gets the vaccination, then she will be protected from cancer, and there will be no infection in the future. I will feel relieved. (Nepalese mother, N21)

High Perceived Severity of the Diseases

All South Asian mothers agreed that the consequences of HPV infection and cervical cancer were severe. They considered cancer to be a scary and dangerous issue. Besides, they worried that their daughters would be labelled due to the diseases.

Of course, in our society, very few people have knowledge about it; they will think in a negative way. So, they’ll say, oh this is a sexual disease and transmitted through sex, and so they might have relations with boys and something like that. (Nepalese mother, N10)

Barriers Hindering Chinese Mothers’ Decisions to Vaccinate Their Daughters

Two categories were derived to describe the barriers hindering Chinese mothers’ decisions to vaccinate their daughters against HPV: 1) inadequate knowledge of cervical cancer, HPV and the HPV vaccine and 2) high perceived barriers to HPV vaccination due to vaccine cost.

Inadequate Knowledge of Cervical Cancer, HPV, and the HPV Vaccine

All Chinese mothers had basic knowledge of the disease and the vaccine. However, they would like to know more about the efficacy, side effects and the recommended age for vaccination.

I know this vaccine. I know this target certain types of HPV, and there is an age range to receive the vaccine, but I do not know the exact age and the exact targeted HPV types. (Chinese mother, C12)

High Perceived Barriers to HPV Vaccination Due to Vaccine Cost

Although mothers claimed that they would not be stopped from vaccinating their daughters due to the cost, some mothers expressed that they would delay the schedule and arrange the vaccination for when they felt their daughters really needed it.

The cost is high. I would bring my daughter to receive this vaccine when it is necessary. (Chinese mother, C10)

Facilitators Enhancing Chinese Mothers’ Decisions to Vaccinate Their Daughters

Four categories were derived to describe the facilitators enhancing Chinese mothers’ decisions to vaccinate their daughters against HPV: 1) positive influence and support from external sources, 2) high perceived benefit of the HPV vaccination, 3) high perceived susceptibility to cervical cancer and HPV infection, and 4) low perceived barriers due to vaccine safety and side effects.

Positive Influences and Support from External Sources

Receiving HPV vaccine information from reliable sources, recommendations from healthcare professionals and vaccination programmes arranged by schools and the government could positively reinforce Chinese mothers’ decisions to let their daughters receive the HPV vaccination.

HPV Vaccine Information from Reliable Sources

Chinese mothers agreed that HPV vaccine information from their doctors, government websites, schools or the government are reliable. They believed that the information from these sources was reliable and positively influenced their decision.

Their (doctors and nurses) advice is critical and affects me more. This [HPV] vaccine is on the list, and the Department of Health asked that our children of the suitable age receive this vaccine. (Chinese mother, C03)

HPV Vaccination Recommendations from Healthcare Professionals

Some Chinese mothers received advice from healthcare professionals regarding the HPV vaccine. They claimed that this recommendation could positively influence their decision-making.

Three years ago, I asked the doctor about this vaccine, and he suggested that my daughter receives the HPV vaccine three years later when she becomes nine years old. I believe his advice. (Chinese mother, C06)

Availability of HPV Vaccination Programmes Arranged by Schools and the Government

Chinese mothers agreed that the available HPV vaccination programme arranged by schools and the government not only increase mothers’ confidence in the safety of the vaccine, but also mothers would not need to spare extra time to arrange the vaccination.

If this (HPV vaccination) is arranged by the school, your motivation will be greater. You will think the need to receive this vaccine becomes greater, as the government recommends that this be done. (Chinese mother, C02)

High Perceived Benefit of HPV Vaccination

Chinese mothers felt that the HPV vaccine could help in preventing HPV infection and cervical cancer. Most Chinese mothers agreed that the benefits of the HPV vaccine were high, and this was one of the important facilitators influencing their decision.

Because I know it offers effective protection from cervical cancer, I feel that it is necessary to do. (Chinese mother, C05)

High Perceived Susceptibility to Cervical Cancer and HPV Infection

Chinese mothers reported they were open-minded to sexual relationships and expressed that they might not know about their daughters’ sexual life when they reached mid-adolescence. Some mothers also thought that even though their daughters only had one partner, there could still be a risk of contracting the virus in the future.

It is difficult to tell. I will let her have this vaccine when she is in secondary three or four. I don’t know what will happen at that time. She has her life, and I won’t know about her sexual life by then. (Chinese mother, C12)

Low Perceived Barriers Due to Vaccine Safety and Side Effects

Nearly all Chinese mothers felt that this HPV vaccine was safe, and they had few concerns about the side effects. As the vaccine had been on the market for a long time, there has not been much news reporting safety and side effects issues.

I can’t see any news reporting about this vaccine. Now, more research has investigated the effects of this vaccine, and it has been used for a long time. I don’t think about these (safety and side effects). (Chinese mother, C09)

Similarities and Differences in the Barriers and Facilitators Influencing HPV Vaccination Decisions Among South Asian and Chinese Mothers

Five influencing factors were common to both groups (Table 3). These included inadequate knowledge of the diseases or HPV vaccine, perceived barriers to vaccination due to vaccine cost, receiving information from reliable sources, availability of HPV vaccination programmes and the perceived benefit of HPV vaccination. Some barriers and facilitators were only observed among the South Asian mothers. These barriers included inadequate awareness about the disease or the HPV vaccine; low perceived susceptibility to HPV and need for vaccination; perceived barriers to HPV vaccination due to vaccine safety, side effects and language problems. Influences from internal and external sources played significant roles in the HPV vaccine uptake among South Asian mothers, who emphasised that family support, especially that of the husband, would influence their decision-making. Although mothers might have the autonomy to make the decision, they highlighted that they would discuss any important decision with their husbands and provide them with the necessary information. This was a joint decision between the mother and father. Pakistani mothers, in particular, expressed the importance of their husbands’ agreement on the decision.

Table 3 A comparison of the similarities and differences in the barriers and facilitators to HPV vaccination between South Asian and Chinese mothers
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Discussion

This is the first study of its kind to compare Chinese mothers with South Asian mothers in terms of the factors influencing their decisions to vaccinate their daughters against HPV. This study identified the barriers and facilitators influencing mothers’ decisions to vaccinate their daughters. Although some commonality exists, our study findings showed that South Asian mothers experienced more barriers than Chinese mothers in making the vaccination decision. Some of these barriers were consistent with those identified in a previous review, including inadequate awareness of cervical cancer and the vaccine; perceived barriers due to vaccine side effects and language problems; absence of healthcare professionals’ recommendations; and religious and cultural beliefs. Moreover, the present study revealed that only the South Asian mothers highly valued family support when making their decisions. These mothers said that they would discuss any important decisions with their husbands and provide them with the information before making the final decision. They expressed that the decision to have HPV vaccination should be a joint decision between the mother and father. This study attempted to highlight the specific needs of each ethnic group to inform the government and encourage it to devise and implement interventions and policies to address these specific needs.

Inadequate awareness of cervical cancer, HPV and the HPV vaccine was observed among South Asian mothers, consistent with previous studies in which some South Asian mothers reported it was their first time learning about cervical cancer, HPV and the HPV vaccine [6, 14]. This inadequate awareness could be due to language barriers and cultural teachings. South Asian women tend not to talk about cervical health in their community or at home, and they expressed feeling embarrassed during the discussion of this topic. Moreover, they seldom have opportunities to learn about HPV in their communities [6, 14]. Language also creates a barrier for these women to learn about the topic. Most of the current materials promoting HPV vaccination in Hong Kong are delivered in English and Cantonese via mass media, such as television advertisements, promotional posters, and leaflets in health clinics [10]. This information is likely to reach the Chinese population but not the South Asian population, as these are not channels commonly used by South Asian mothers to receive information, and not all of them understand Cantonese and/or English. South Asian mothers revealed that they usually obtain information via YouTube or social media platforms, such as Facebook, WhatsApp, or Instagram [21]. They choose to obtain information from pages on these platforms that they deem to be reliable, such as those that are managed by the government. Although the Centre for Health Protection of the Department of Health has a YouTube channel and Facebook page with multiple promotional videos related to topics such as cancer screening and COVID-19 vaccines produced in the language understood by South Asians, no such videos on the topic of HPV vaccination are available [10]. Producing linguistically appropriate materials (videos, posters and leaflets) is necessary for improving South Asian women’s awareness of this topic. These materials should be disseminated through channels accessible to South Asians, such as community centres supporting ethnic minorities and the health clinics they visit. Community-based education intervention targeting South Asian mothers could also be conducted in rooms within the community centres to minimise embarrassment. Onsite interpreters should be available to interpret the educational talks into languages spoken by South Asian women [22]. In addition, linguistically appropriate promotional videos could be uploaded to the YouTube channel and Facebook page of the Centre for Health Protection so that more South Asian women could get the most updated information.

A perceived barrier commonly mentioned by South Asian mothers was the language barrier. Language barriers are consistently reported to be a significant issue affecting ethnic minorities’ utilisation of health services [6, 23, 24]. In Hong Kong, all healthcare professionals speak fluent Cantonese, and most can also communicate with English-speaking clients in English. South Asian mothers who lack English and/or Cantonese/Chinese proficiency have difficulty understanding explanations from healthcare professionals during medical consultations and are not able to communicate their needs clearly [6, 14]. To solve this problem, interpreter services should be provided to support ethnic minorities in accessing and utilising health services. In Hong Kong, both onsite and telephone interpretation services are available, and the operation hours are typically 8:00–14:00 h. South Asian mothers can book the service at least three working days in advance before they attend their scheduled appointment [25, 26]. However, the interpreter service is not guaranteed and may be affected by the availability of the medical interpreter [25], HKSKH Lady MacLehose Centre [26]. For better delivery of interpretation services, more resources and efforts should be allocated to these services, including training more medical interpreters and the provision of 24-h interpretation services (both onsite and telephone services) to improve access to health services by ethnic minorities, especially emergency services [27].

A number of internal and external influences affected South Asian mothers’ decisions to have their daughters vaccinated against HPV. Seeking advice and support from family was only mentioned by South Asian mothers, not Chinese mothers, and was expressed to be particularly important among South Asian families. South Asian mothers considered that it was their responsibility to discuss the matter with their husbands and sought their support [23]. Although Indian and Nepalese mothers in the current study mentioned that they had the autonomy to make the decision, as they are their daughters’ main caregivers, they all emphasised that HPV vaccination should be a joint decision between mother and father. A study found that South Asian women tended to follow their husbands’ advice to avoid family conflicts [23]. In the current study, it was observed among the Pakistani mothers. They expressed that they would listen to husband’s opinion and follow their decision regarding the vaccination of their daughters. Our findings are inconsistent with the findings of a previous study conducted in the UK among South Asian mothers [28]. Marlow et al. (2009) found that 31% and 32% of their studied Indian and Pakistani mothers took the lead role in deciding whether their daughters should receive the HPV vaccine, and 61% and 57% of the studied Indian and Pakistani mothers expressed that this was a joint decision with the father. Only 9% and 10% of the Indian and Pakistani mothers, respectively, mentioned that the father took the lead role in making the decision [28]. Compared with Marlow et al. (2009) [28], the present study found that South Asian fathers had more involvement in the joint decision. Therefore, they play important roles in making healthcare-related decisions for their children and they may even take the lead role in making such decisions. Most current HPV vaccine campaigns and promotional interventions focus on adolescent girls and their mothers only. However, the findings of the present study indicate that interventions targeting their fathers only or family-based interventions should also be used, so that fathers are included in discussions about whether their daughters should receive HPV vaccination.

Although South Asian mothers mentioned that their religions did not place restrictions on the vaccination practice, religious teachings did provide some guidance in Muslim mothers’ beliefs in relation to their daughters’ susceptibility to the disease and their need to receive the vaccine. Consistent with previous studies, Muslim mothers thought that their daughters were at low risk of contracting HPV infection and cervical cancer as their daughters would not engage in sexual activity before marriage, following the teaching of their religion [14, 29]. Apart from this, South Asian mothers thought that the discussion of health topics related to cancer in public areas was inappropriate; thus, they were less likely than other groups to actively discuss the topic with healthcare professionals [23]. Thus, during medical consultations, healthcare professionals should try to be more proactive in offering preventive health advice to South Asians. Moreover, healthcare professionals should be prepared and trained to be more culturally sensitive so that they can offer relevant advice with respect to South Asian religious and cultural teachings [6, 14].

The South Asian mothers mentioned that the availability of a subsidy for the HPV vaccine would positively reinforce their vaccination decision, but this was not discussed as an influencing factor by Chinese mothers. The importance of this factor may be related to the financial status of South Asian mothers in Hong Kong. According to the population census, the monthly household income of most South Asian families was below the overall median monthly income in Hong Kong [13]. Financial constraints would make it hard for them to pay for the vaccine, but if subsidies were available, the cost might not be a barrier preventing South Asian mothers from getting their daughters vaccinated. A previous HPV vaccination pilot programme supported by the Community Care Fund in 2016–2019 revealed that offering a free or low-cost HPV vaccine to low-income families attracted more than 26,000 girls to receive the vaccine [30]. Similar programmes can be introduced to support vaccine uptake among adolescent girls who would like to receive the vaccine but could not bear the high cost.

The current study findings will have implications for both clinical practice and policy. To enhance South Asian and Chinese mothers’ knowledge and awareness of cervical cancer, HPV and the HPV vaccine, community-based health promotional campaigns should be conducted regularly, with emphasis on the link between cervical cancer and HPV and the HPV vaccine safety and side effects. If possible, these campaigns should be conducted at least 6 months before the Hong Kong Childhood Immunisation Programme becomes available for the mothers of eligible primary students. These campaigns should be delivered by either healthcare professionals or schoolteachers who are knowledgeable about cervical health and the HPV vaccine. In view of the religious and cultural beliefs of South Asian mothers, training should be offered to enhance healthcare professionals’ and schoolteachers’ cultural sensitivity when offering advice or delivering campaigns. Linguistically appropriate materials, such as videos, posters and leaflets, should be prepared to facilitate South Asian mothers’ understanding of the information. These materials should also be disseminated via channels commonly used and trusted by the mothers, such as YouTube channels or Facebook pages managed by governmental organisations. Whenever possible, onsite interpreters should be arranged during the campaigns. Because there is a lack of available medical interpreters, resources should be allocated to train additional medical interpreters. Moreover, the government may consider resuming the provision of financial subsidies for low-income families to received HPV vaccination, such as the Community Care Fund. Family support is important among South Asian families; thus, interventions that include both fathers and mothers in discussions of HPV vaccinations could be organised to improve their understanding of the importance of HPV vaccination for their daughters’ health.

There were discrepancies in the number of mothers recruited from each ethnic group. In particular, only 12 Chinese mothers participated in this study. Several studies have been conducted in Hong Kong on the factors affecting Chinese mothers’ decisions on whether their daughters receive the HPV vaccine [31,32,33]. However, no studies have been conducted to review the barriers to and facilitators of South Asian mothers having their daughters receive the HPV vaccine. Among Chinese mothers, several barriers and facilitators have been documented, such as the perceived benefits of vaccination, perceived self-efficacy in obtaining the vaccine, cost of the vaccine and lack of knowledge about HPV and the HPV vaccine. In the present study, we conducted ongoing data analysis and reviewed the codes and categories generated from the focus group interviews. The categories generated were similar to those identified in previous studies performed in Hong Kong. In addition, the literature suggested that three focus group interviews would be sufficient to identify the most prevalent categories within the data [34]. Thus, we conducted three focus group interviews with 12 Chinese mothers.

There are some limitations that need to be acknowledged. First, the participants were recruited from only a few community centres and ethnic minority associations, which might affect the transferability of our findings to other South Asians in Hong Kong. Second, the study was conducted during the COVID-19 pandemic, and the city was focused on discussing the COVID-19 vaccine, but not other vaccines. The mothers might mix up the different types of vaccines, although we consistently reminded the mothers of the focus of the discussion. Because a focus group interview approach was adopted in this study, the discussion during interviews could have been dominated by mothers who liked to talk and share while other mothers remained comparatively quiet and less active, potentially affecting the findings. Finally, the aim of this study was to explore the barriers and facilitators affecting South Asian and Chinese mothers’ decisions to have their daughters vaccinated against HPV. Therefore, we did not explore mothers’ attitudes toward the acceptability of vaccinating their adolescent sons, their views toward early vaccination, or the barriers to completing the vaccine series. With the increased emphasis on the importance of HPV vaccination for both boys and girls, further studies are warranted to explore these issues.

Conclusions

This study identified certain barriers and facilitators that hinder or support South Asian and Chinese mothers’ decisions to vaccinate their daughters against HPV. The comparison between groups improves our understanding of the unique barriers experienced by South Asians in Hong Kong. The findings inform the development and implementation of relevant intervention to improve HPV vaccine uptake among the South Asian and Chinese adolescent girls in Hong Kong.