(HPV) and Increasing Vaccination Rates: a Literature Review

PROJECT

CALIFORNIA STATE UNIVERSITY SAN MARCOS

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF PUBLIC HEAL TH

TITLE: An Assessment of Theory and Practice of Human Papilloma Virus (HPV) and Increasing Vaccination Rates: A Literature Review

AUTHOR(S): Catalina Godinez

DATE OF SUCCESSFUL DEFENSE: 04/28/2020

THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COMMITTEE IN

PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREEOF

MASTER OF PUBLIC HEALTH

Deborah Morton Apr 30, 2020 COMMITTEE CHAIR SIGNATURE DATE

Christina Holub May 1, 2020 COMMITTEE MEMBER DATE

COMMITTEE MEMBER SIGNATURE DATE

COMMITTEE MEMBER SIGNATURE DATE Running Head: An Assessment of Theory and Practice 1

An Assessment of Theory and Practice of Human Papillomavirus (HPV) and Increasing Vaccination Rates: A Literature Review

Catalina Godinez California State University, San Marcos Thesis April 28, 2020

An Assessment of Theory and Practice 2

Abstract

Human Papillomavirus (HPV) is a sexually transmitted disease that can cause many types of cancers, including cervical cancer in women. HPV is one of the most common sexually transmitted diseases world-wide. Three types of HPV immunizations are available to vaccinate against the most prevalent strains of HPV that cause both genital warts and cancer. Although these vaccinations are available for girls and women ages 9-26, there is still inadequate vaccination uptake. Behavior change theories have been used to increase intention to vaccinate and vaccination rates among adolescents in many studies. This review examined studies that employed various behavior change theories. Its goal was to understand which theory is most effective in increasing vaccination rates. After analyzing the articles, there was insufficient data to suggest one theory is more effective than others. However, the theory of planned behavior and a mixed method theory were used most often for the design of research studies and interventions.

An Assessment of Theory and Practice 3

Acknowledgements

I would like to thank my chair, Dr. Morton, for her continued encouragement throughout this process. I would also like to thank Dr. Holub who has been a tremendous help. I would like to thank my family and friends who have been extremely supportive during this time. Lastly, thank you to cohort 6 for being consistently supportive from the start of this program to the end.

An Assessment of Theory and Practice 4

List of Tables

Table 1. Number of Articles Distributed by Theory Type

Table 2. Number of Articles Distributed by Audience Type

An Assessment of Theory and Practice 5

List of Figures

Figure 1. Flow Chart of Articles Included in Systematic Literature Review.

An Assessment of Theory and Practice 6

Table of Contents

Abstract 2 Acknowledgements 3 List of Tables 4 List of Figures 5 Introduction 7 Statement of Problem 7 Literature Review 8 Etiology of HPV 8 Effects of HPV globally 9 Effects of HPV within the U.S. 10 Risk Factors 10 Descriptions of Theories Used 12 Research Goal 14 Methods 15 Search Strategy 15 Study Characteristics 17 Results 17 Summary of article search 17 Articles characteristics 18 References 27 Appendix 30

An Assessment of Theory and Practice 7

Introduction Human Papillomavirus (HPV) is a major public health problem globally. In 2006, a vaccine became available to immunize people against the most common strains of HPV.

However, vaccine uptake remains relatively low. To increase vaccination rates, a variety of health behavior change theories have been used to increase both intentions to vaccinate and vaccination uptake rates. This paper presents the results of a systematic literature review to assess which behavior change theory is most effective to increase intention rates and HPV vaccination rates.

Statement of Problem HPV can be considered asymptomatic. Most people who contract HPV show no signs or symptoms, except for those who experience the type of HPV that manifests as genital warts

(Center for Disease Control, 2017b). Currently, only women are tested for HPV, usually during a pap smear exam (Center for Disease Control, 2017b). HPV is most prevalent in younger people.

Its incidence peaks at 25 years old and slowly declines after (Serrano et al., 2018). Men are less likely to show symptoms, yet they can still be carriers. The World Health Organization estimates that by the year 2030, there will be 27 million new cases of cervical cancer and 17 million deaths worldwide (Araldi et al., 2018). In the past 20 years, the incidence of cancers related to HPV has increased by 225 percent (Center for Disease Control, 2018). HPV is therefore considered to be a major threat to public health.

In 2006, the U.S. Food and Drug Administration approved HPV vaccination for girls and young women ages 9–26 (Agenor et al., 2015). However, in 2013, only 44.7% of women 19–21 years old were vaccinated (Williams et al., 2015). Vaccinations are important because the use of condoms alone will not prevent every case of HPV (Gerend & Shepherd, 2012). These vaccines An Assessment of Theory and Practice 8 are given in two or three doses, depending on the kind of vaccine. It is important to complete the series of vaccinations in order to properly prevent high risk HPV.

To improve vaccination uptake, public health officials design intervention programs guided by health behavior theories. These theories are systematic models for understanding and guiding people’s thinking, choices, and actions to improve individual and public health outcomes. For example, one widely-used theoretical framework is the Health Belief Model

(HBM), which focuses on how personal attitudes, beliefs, and perceptions influence health behavior (Skinner, Tiro, & Champion, 2015). HBM was developed by social psychologists in the

U.S. Public Health Service in the 1950s to explain changes in health behaviors and guide the design of effective interventions. It has been used successfully to address many public health challenges, including how to increase rates of colon cancer screening and HPV vaccination

(Skinner, Tiro, & Champion, 2015). Examples of other health behavior theories include Theory of Planned Behavior, Theory of Reasoned Action, Reasoned Action Approach, and Social

Cognitive Theory. Despite almost fifteen years of study, it is not yet clear which theory is most effective for increasing intention and vaccination rates in the context of HPV prevention.

Literature Review Prior to conducting the systematic literature review, I first reviewed background literature on HPV. This section describes the etiology of HPV, its effective globally and in the United

States, and risk factors associated with HPV. It then describes five of the mostly widely used theories of behavior change in the context of HPV prevention.

Etiology of HPV An Assessment of Theory and Practice 9

Human Papillomavirus (HPV) is a virus transmitted through sexual contact that causes serious health consequences if it is not properly identified and treated (National Foundation for

Infectious Diseases, 2014). Infection occurs when the virus enters the body, usually through a small cut in the skin or mucous membranes (Brianti, De Flammineis, & Mercuri, 2017). HPVs are categorized into two subgroups based on the level of potential health risk they pose: high risk

HPVs (HR) and low risk HPVs (LR). The HR strains of HPV are associated with the public health threats of HPV, such as cancer and genital warts (Brianti et al., 2017). The most prevalent

HPV strains include: 16, 18, 31, 33, 45, 6, 11. (Araldi, Sant’Ana, Modolo, de Melo, Spadacci-

Morena, Stocco, Cerutti, & de Souza, 2018). Some of these strains of HPV are associated with oral cancers, anal cancers, penile cancers in men, and various female reproductive system cancers (Center for Disease Control, 2017a). The most common of these cancers is cervical cancer, which is the third most common type of cancer in women and the fourth most leading causes of death related to cancer worldwide (Araldi et al., 2018).

Effects of HPV globally

Globally HPV has affected many women. Data shows that there were 570,000 cases of cancers related to HPV that affected women, of these cases 530,000 were cervical cancer (De

Martel, Plummer, Vignat, & Franceschi, 2017). Cervical cancer is the 4th most frequent cancer in women and accounts for 7.5% of all female cancer related deaths. Over 2/3rds of the cases were diagnosed in less than developed nations which makes HPV vaccination imperative in these countries (De Martel et al., 2017). With global introduction of vaccines, women should get vaccinated in order to prevent the two strains, HPV 16 and 18 that accounted for 70% of global cervical cancer cases in 2012 (World Health Organization, 2018). The World Health

Organization also estimated that out of the 311,000 cervical cancer deaths yearly world-wide An Assessment of Theory and Practice 10 more than 85% of these will occur in less than developed regions. Globally the high mortality rate from cervical cancer (6.9/100,000) could be reduced by effective intervention (World Health

Organization,2018).

Effects of HPV within the U.S.

Within the United States HPV is a huge burden on women’s health. HPV is the most common sexually transmitted infection in the United States, (Center for Disease Control, 2017a).

More than 79 million Americans are infected with one or more strains of HPV (Center for

Disease Control, 2017a). It was estimated that over 33,700 cancer cases are caused by HPV each year (Center for Disease Control, 2019). The center for disease control and prevention reported

12,984 new cases of cervical cancer and 4,188 women died of cervical cancer in 2016.

Risk Factors

Associated risk factors of HPV include unprotected sexual contact, lack of knowledge, and lack of vaccination.

Unprotected sexual contact. HPV is a sexually transmitted infection that requires close skin to skin contact for transmission. It spreads through vaginal, oral, and anal sexual intercourse. Unprotected sexual contact increases risk of HPV infection (Van Dyne Henley,

Saraiya, Thomas, Markowitz, & Benard, 2018). The use of latex condoms can reduce infection

(Center for Disease Control, 2017). However, male and female adolescents often do not use condoms, especially those who believe condoms reduce sexual pleasure (Jones & Miller, 2016).

This increases their risk of developing sexually transmitted diseases like HPV (Mullins, et al.,

2016). An Assessment of Theory and Practice 11

Lack of knowledge. Another risk factor for HPV infection is lack of knowledge regarding what HPV is, how it is transmitted, and how it can be prevented (Ellis, Ferrer, & Klein,

2018; Lopez & McMahan, 2007). A cross-sectional study by McBride and colleagues sampled

3,103 individuals to assess their knowledge and awareness about HPV. Their regression analysis tested for the best predictors of general HPV knowledge, finding that sociodemographic characteristics such as race, ethnicity, income, education level, and gender are indicators of general HPV knowledge. Knowledge about the relationship between HPV and cancer was relatively low for all individuals. Being a female, having some college education, and having median to high household income indicated more knowledge regarding HPV (McBride et al.,

2018). Similarly, a mixed methods study of Black adolescent females in Pennsylvania found that

36 percent of respondents were unaware of the existence of an HPV vaccines. Focus groups participants stated that having more information would increase uptake of HPV vaccination

(Brawner et al., 2013).

Being unvaccinated. In the last two decades, three different types of vaccines have been developed to combat different strains of HPV. However, the uptake of these vaccines has been low. These vaccines are given in two or three doses, depending on the kind of vaccine. Jorge and

Wright (2016) found that up to 60% of adolescent girls and 40% of adolescent boys receive one or more HPV vaccination doses. However, of these adolescents, only 40% of girls and 20% of boys finish the recommended series of doses. Barriers associated with reduced completion of the

HPV vaccination series include financial or insurance coverage issues, irregular preventative care, and lack of information regarding the vaccination and the virus (Jorge and Wright, 2016).

These barriers are influenced by beliefs, attitudes, or concerns expressed by parents about the An Assessment of Theory and Practice 12 safety and potential side effects of vaccination and whether or not it will impact the adolescent’s sexual behavior (Jorge and Wright, 2016).

Descriptions of Theories Used

These health behavior change theories and models were developed to explain and increase women’s intention to vaccinate, or to increase vaccination rates. The following is a description of each theory as it pertains to increasing HPV vaccination intention and uptake.

Health Belief Model. The health belief model has six building blocks or constructs that influence behavior change (Sharma, Branscum, Atri, 2014). The first building block is perceived susceptibility, which is a woman’s belief that she will develop HPV or experience negative effects due to HPV if she does not or does get the HPV vaccine. The second construct looks at the perceived severity of contracting HPV, meaning how serious a woman believes this disease is and what consequences it can bring. In tandem, those two constructs comprise perceived threat, the degree to which a woman believes this disease will affect her and, if it does, how severe it will be. Perceived benefits are the advantages a woman expects to experience by changing behavior or getting vaccinated against HPV. Perceived barriers looks at the obstacles women believe impede getting vaccinated. The next building block is cues to action, the environmental or internal triggers that influence a woman’s behavior change. The final building block in the model is self-efficacy which is the woman’s confidence in her ability to get the HPV vaccination.

Together these building blocks work to change an individual’s behavior.

Theory of Reasoned Action. The theory of reasoned action focuses on subjective norms, behavioral intentions, and attitudes toward the behavior (Sharma, Branscum, Atri, 2014).

Behavior intentions are a woman’s readiness towards getting vaccinated or the likelihood of An Assessment of Theory and Practice 13

them getting vaccinated. The next building block is attitudes towards the behavior change. This

is the woman’s overall mindset about getting the HPV vaccination. This building block has two

sub-constructs: outcome evaluations and behavioral beliefs. Behavioral beliefs are the perceived outcomes of getting the vaccine. Outcome evaluations is evaluating all the possible outcomes considered and assessing their long-term effects. The final building block is subjective norms,

which is an evaluation of how the most important people in an individual’s life would want them

to act. This building block also looks at normative beliefs which is an assessment of how those

important people would feel about changing the behavior, in this case getting vaccinated. The

motivation to comply is determined by how much the woman values each person’s opinion.

Theory of Planned Behavior. The theory of planned behavior adds to the building

blocks of the theory of reasoned actions. The first added building block is perceived behavioral

control, which is the woman’s belief that she is in control of deciding to change the behavior.

This is shaped by two other constructs: control beliefs, which is the women’s beliefs of barriers

that will hinder their ability to get the HPV vaccination and perceived power, which is the women’s perception on how easy or difficult it will be to get the HPV vaccine (Sharma,

Branscum, Atri, 2014).

Social Cognitive Theory. This focus of this theory is on self-efficacy, stating that people

are driven by a triad relationship between behaviors, cognitive, and personal factors and

environmental cues or events (Sharma, Branscum, Atri, 2014). The theory has five main building

blocks. The first one is knowledge, which is a woman’s understanding of how engaging in (or not

engaging in) the behavior change may lead to risk or benefits. The next building block is

perceived self-efficacy. This is the confidence a person senses in his or her ability to make the

behavior change. Perceived facilitators and impediments is the next building block. This focuses An Assessment of Theory and Practice 14

on real or perceived environmental factors that can enable or hinder behavior change (Sharma,

Branscum, Atri, 2014). The next building block is outcome expectations. This is the

consequences that women perceive to be associated with the behavior change. The final building

block is goal setting, the development of short-term and long-term goals to maintain the behavior change.

Reasoned Action Approach. According to an article by Conner et al. the reasoned action approach was developed out of both the theory of reasoned action and the theory of planned behavior. In this model experimental attitudes, instrumental attitudes, descriptive norms, injunctive norms, capacity, and autonomy all lead to intention which leads to behavior change or action (Conner et al., 2017).

Research Goal Numerous studies have investigated the etiology and risk factors associated with HPV, as well as the efficacy of interventions to increase vaccination rates. However, there is still limited understanding of how public health programs can effectively increase vaccination uptake.

Behavior change theories have guided the design of many studies to increase HPV vaccination rates and intention, yet few systematic comparisons have been made to assess which theory is most effective in increasing HPV vaccination intention and uptake. The aims of this systematic literature review are: (1) to identify and compare theoretical behavior change models and their effectiveness in promoting use of vaccines that prevent HPV, and (2) to identify factors and variables that impact HPV vaccination rates among young women.

A previous study by Batista Ferrer and colleagues (2015) conducted an appraisal on

health behavior change theories and HPV vaccination uptake. That study looked at articles

published through December 2013, concluding it was not possible to discern which model or An Assessment of Theory and Practice 15 theory was best for increasing vaccination uptake (Batista Ferrer et. al, 2015). In the last several years, dozens of studies on HPV vaccinations using behavior change theories have been published, but a search of peer-reviewed literature could find no new systematic reviews examining the effectiveness of behavior change theories to increase HPV vaccination uptake. To address this knowledge gap, I conducted a systematic literature review to answer my research question: What behavior change theories have been most effective in increasing HPV vaccination intention and rates for girls and women ages 9-26? My review builds on previous research, focusing on newer studies conducted since 2013.

Methods A systematic literature review was undertaken to appraise which health behavior change theory is most effective in increasing HPV vaccination intentions and uptake among females ages 9-26 years old. The research focused only on behavior change theories used to increase the rates of intention to vaccinate or to increase vaccination rates. The goal was to assess which health behavior change theory outperformed the others. It did not focus on theories that were not related to behavior change or finding a solution to increase vaccination rates, but rather to discern the most effective approach.

Search Strategy

The database used was CINAHL Complete, which is an EBSCO host database.

Keywords searched were “‘human papillomavirus vaccine”, ‘hpv vaccination’”, or ‘hpv vaccine’ AND ‘rate or statistics’ AND ‘health behavior theory’”; “‘human papillomavirus vaccine or hpv vaccination, or hpv vaccine’ AND ‘health belief model’”; “‘human papillomavirus vaccine or hpv vaccination, or hpv vaccine’ AND ‘theory of planned behavior or theory of reasoned action’”, and “‘human papillomavirus vaccine or hpv vaccination, or hpv An Assessment of Theory and Practice 16

vaccine’ AND ‘social cognitive theory’”. Only articles published since 2006 were included,

since the HPV vaccination was introduced that year.

The results of interest were behavior changes in the target population due to the use of a

health behavior change theory that influenced the rate of intentions or rate of vaccination uptake.

A review of the titles and abstracts was performed to determine if the search results were

appropriate to the results of interest. The studies that were aligned with the results of interest

were included in this literature review.

Inclusion Criteria: Inclusion was limited to peer-reviewed journals that published empirical studies, reviews, and interventions to examine rates of intention and HPV vaccination.

The articles must also include a behavior change theory (health belief model, theory of planned behavior, theory of reasoned action, reason action approach, and social cognitive theory) used to increase rates of intention or vaccination rates. These theories were selected because they are frequently used to assess rates of behavior change in the context of public health change

(Sharma, Branscum, Atri, 2014).

Inclusion was also limited to studies conducted within the United States. The articles had to include studies done within any of the 50 US states. These studies could include interventions or systematic reviews done within the US or using US data.

Further inclusion criteria were publication date, age, gender, and targeted audience.

Articles published prior to 2006 were excluded, since the HPV vaccine was introduced in the US that year. The age range was girls who are 9-26 years old, since this is the age range for female vaccination. The articles must focus on increasing female vaccination rates. Females were selected because they have a higher mortality rate from HPV-related cancers. Studies were An Assessment of Theory and Practice 17 limited to a target audience of parents/ guardians and girls ages 9-26. Most studies targeted females ages 9-26 or parents or guardians of daughters in this age range to increase intentions to vaccinate or vaccination uptake.

Exclusion Criteria: Articles excluded were studies that included males, conducted outside the US, not published in English, and involving subjects outside the 9-26 age range.

Articles that targeted physicians as the only intended audience were also excluded because the focus in on patient behavior change, not physician behavior change. Articles that were not peer reviewed were also excluded.

Study Characteristics

Articles were categorized by the type of theory used (e.g. theory of planned behavior, health belief model, social cognitive theory, etc.). Six articles used the theory of planned behavior, one article used the health belief model, one article used the social cognitive theory, and one article used the theory of reasoned action in combination with the health belief theory.

Six articles used a mix of theories, combining constructs of multiple theories. Articles were also sorted by intended audience. Seven studies were conducted to study behavior change in parents or guardians; six studies were conducted to investigate behavior change in females ages 9-26 years old; and two studies examined behavior change in both parents and females ages 9-18.

Results Summary of article search An Assessment of Theory and Practice 18

This systematic literature review assessed articles with theoretical frameworks that helped increase vaccination rates among females ages 9-26 years of age. Articles were analyzed to identify recurring themes regarding barriers to HPV vaccination and intent to vaccinate.

A search using the keywords yielded 117 articles. After further analyzing the articles, 60 were excluded due to the abstract not aligning with the research goals. Of the remaining 117 articles, further exclusions were done due to gender which excluded 36, region which excluded

57, and age range which excluded 9, leaving a total of 15 articles to be analyzed. See figure 1 for a visual of article chart with exclusions.

Articles characteristics

Of the total articles (15), six used the theory of planned behavior as a model to increase intention to vaccinate or vaccination rates. One article used the health belief model. One article used the social cognitive theory. One article used the theory of reasoned action. The rest of the articles (6) used a mixed theory approach to increasing vaccination rates or intention to vaccinate. The combinations were: theory of planned behavior and health belief model (3), health belief model and theory of reasoned action (1), reasoned action approach and health belief model (1), and health belief model, social cognitive theory and theory of planned behavior (1).

Themes An Assessment of Theory and Practice 19

Common themes identified in the articles included barriers for intention to vaccinate and vaccination uptake. Some of these barriers included: knowledge about HPV and HPV vaccination, misconceptions and beliefs about HPV vaccines, and health insurance coverage.

Most articles attempted to address these barriers while adding to the literature on the problem of low vaccination uptake rates. Articles were further analyzed by theory effectiveness, factors enhancing effectiveness, and factors inhibiting effectiveness.

Effectiveness of theories. The effectiveness of theories was determined by analyzing articles for an increase in intention to vaccinate or vaccination uptake. Most articles analyzed parents and/or young women’s knowledge and used constructs from theories to measure or to create an intervention to increase intention to vaccinate and/or vaccination uptake. The first finding was that the theory of planned behavior was used the most as a stand-alone theory in six studies (Askelson et al., 2010; Brawner et al., 2013; Brueggmann et al., 2015; Miller, Wickliffe,

Jahnke, Linebarger, and Humiston, 2014; Teitelman et al., 2011; Valdez, Stewart, Tanjasari,

Levy, and Garza, 2015). In these studies, the use of TPB constructs and attitudes and beliefs

(both normative and subjective) were measures used to increase parents’ intention to vaccinate and/or vaccination uptake for their children or for young women.

The second finding was the use of a mixed theory approach used in six of the articles (Aragones,

Genoff, Gonzalez, Shuk, and Gany, 2015; Gerend & Shepherd, 2012; Gerend, Weibley, and

Bland, 2009; Jozkowski & Geshnizjani, 2016; Lechuga, Vera-Cala, and Martinez-Donate, 2016;

Reynolds & O’ Connell, 2011). These articles used constructs from two or more theories to analyze or design methods to increase intention to vaccinate or vaccination uptake. They did not employ a single theory, but rather borrowed constructs from multiple theories to tackle barriers that were seen in their study. Out of these studies, three combined constructs from TPB and An Assessment of Theory and Practice 20

HBM (Gerend & Shepherd, 2012; Gerend, Weibley, and Bland, 2009; Lechuga, Vera-Cala, and

Marinez-Donate, 2016). The HBM constructs mostly used in these articles were perceived susceptibility, perceived severity, perceived barriers, perceived threat, and perceived benefits.

The TPB constructs used were behavior intentions, subjective and normative norms. One article integrated constructs from the HBM and TRA (Reynolds and O’Connell, 2011). The HBM constructs used in this perceived susceptibility, perceived threat, benefit, and barriers, as well as cues to action. The TRA constructs used were behavioral beliefs and normative beliefs. One article used both the RAA and HBM in their study (Jazkowski & Geshnizjani, 2016). The study incorporated attitudes towards the act, perceived norms, and perceived behavioral control from the RAA. It also looked at perceived susceptibility and perceived severity. The last mixed methods article merged constructs from three models: HBM, TPB, and SCT (Aragones et al.,

2015). The constructs used from the HBM were perceived barriers and benefits. The intention construct from the TPB was used as well as the self-efficacy constructs from the SCT.

The third finding was that three articles used one theory. One of these articles used the HBM in their intervention (Cassidy, Braxter, Charron-Pronchwnik, and Shlenk, 2013). The vaccination rate in the group that received the intervention had a 9.4x increase than the control group.

Another article used the TRA (Thomas, Stephens, and Blanchard, 2010). The constructs used in the intervention were beliefs and attitudes as well as subjective norms to increase intentions to vaccinate. The final article used the SCT in their intervention that focused on the self-efficacy construct (Kim & Hmielowski, 2017). The study found that participants (women with an average age of 21) with high self-efficacy were 4.82 times more likely to get the HPV vaccine.

Factors enhancing effectiveness. A variety of factors enhanced theory effectiveness.

The first factor was cultural competency. Three articles tailored their interventions to Latino or An Assessment of Theory and Practice 21

Hispanic individuals (Aragones et al., 2015; Brueggmann et al., 2015; Lechuga et al., 2016). One study tailored their study to Latino/Hispanic and Korean individuals (Valdez et al., 2015). Lastly, three studies had a majority of their participants being African American (Brawner et al., 2013;

Miller et al., 2014; Teitelman et al., 2011). Out of these studies, five of them used the TPB and

two of them used a mixed theory approach. One study that used the TRA also incorporated

culture into their intervention. They applied the culture of hip-hop to increase vaccination rates

(Thomas et al., 2010). The authors of these studies attributed their effectiveness as being due to the intervention being tailored to the participant’s culture and needs.

Another factor that increased effectiveness was including increase in knowledge as an intervention element. When theory-based interventions included an increase of knowledge, it enhanced effectiveness. Eleven articles incorporated an increase of knowledge to their intervention to increase intention to vaccinate or vaccination rate. Some articles included assessments of knowledge in pretest and compared it to a post-test to assess if knowledge was a factor in increasing vaccination rate.

Constructs such as normative beliefs and subjective norms, and attitudes were also found to increase effectiveness of theories. These constructs are derived from the TPB. Brueggmann et al. found that increasing the normative beliefs of parents can increase the intention to vaccinate their children (2015). Studies found that parents' attitudes influence girls and women in getting vaccinated against HPV (Askelson et al., 2010; Brawner et al.,2013; Miller et al., 2014;

Teitelman et al., 2011). This was one of the biggest predictors for vaccination intention.

Physician recommendation was a big predictor of vaccination uptake and intent to vaccinate.

This was seen in multiple studies where participants indicated that physician recommendation was a factor (Gerend and Shepherd, 2012; Gerend et al., 2009; Reynolds and O’Connell, 2011; An Assessment of Theory and Practice 22

Valdez et al., 2015). This falls into the construct of subjective norms and could also be a part of

cues to action.

Factors inhibiting effectiveness. Some factors that inhibited effectiveness of some

theories over others were seen in studies. In the study by Gerend and Shepherd (2012), a

comparison of the HBM and TPB was conducted to see which one was more effective in

increasing vaccination rates. The constructs of both theories were assessed through a survey.

Analysis of survey results found that the constructs from the TPB outperformed those from HBM

(Gerend and Shepherd, 2012). Another factor was the inability for some studies to apply all the constructs of the theory used or the study found that not all constructs applied to certain demographics. Askelson et al. study found that the perceived behavioral control construct from the TPB was problematic in their study due to mother’s feeling that HPV vaccination was in their control. Cost was not a barrier for this demographic group due to health insurance coverage, which impacted perceived behavioral control. A limitation that affected the effectiveness of articles was also that some articles only tested in the present and did not do a follow-up to look at vaccination rates (Lechuga et al., 2016; Thomas et al., 2010; Brueggmann et al., 2016; Miller et al., 2014, Valdez et al., 2015; Teitelman et al., 2011; Reynolds & O’ Connell , 2011; Gerend et al., 2009; Kim & Hmielowski, 2017; Aragones et al., 2015; Jozkowski & Geshnizjani, 2016).

Without this data it is hard to conclude if the theory was effective for the actual vaccination uptake versus intention to vaccinate.

Discussion

Although all the behavior change theories showed some effectiveness in increasing intention and vaccination rates, it is not easy to discern which one theory works best. All the An Assessment of Theory and Practice 23 articles used theories that have shown to be effective in increasing the intentions to vaccinate or vaccination rates. Therefore, it might be worth looking at conducting a different type of study in order to test these theories against one another.

This review found that most studies seeking to increase rates of intention to vaccinate or vaccination rates used either the theory of planned behavior or a mix of different theory constructs. The theory of planned behavior was successful in testing attitudes of the target population, whether it was parents or guardians that had girls eligible for vaccination or eligible girls or young women themselves. Attitudes seemed to be a better predictor for intention to vaccinate as it assessed the attitudes of how the individual felt when it comes to the HPV vaccination. Parents' attitudes and subjective norms were a big predictor for vaccination uptake.

The TPB was used the most which suggests that it is an effective way to measure intentions to vaccinate which can increase vaccination rates. Although, using just one theory can limit other factors that may influence vaccination rates.

The mixed theory approach seems to be more popular in studies. Six of the articles use multiple theories to assess intentions to vaccinate or to create an intervention to vaccinate. This method was successful because it combined important constructs from all theories. Two popular theories that were mixed together most were HBM and TPB. The health belief model incorporated the perceived susceptibility and self-efficacy components which complimented the

TPB.

Factors that increased effectiveness had a lot to do with demographic and audience attitudes. Certain theory constructs also proved to be more useful than others in studies. Being able to distinguish what constructs works is important in creating an effective intervention to get An Assessment of Theory and Practice 24

more girls/young women vaccinated. Factors that decrease effectiveness also include certain

constructs that did not work in certain studies. This was usually due to the fact that some

constructs did not align with the demographic groups. Though they were successful in other

individuals.

Strengths and Limitations

The articles chosen showed how the TPB and a mixed theory approach are good methods

to increase intention to vaccinate and vaccination rates among girls and women ages 9-26. This review had a good mix of different theories. The review also included new studies that continue to build off of previous theory appraisal articles for HPV vaccination. The review also included barriers that were found to hinder vaccination uptake. Major barriers found include: physician recommendation of HPV vaccination can have a strong effect on uptake, parental influence is important to adolescents when making vaccination decisions, increasing knowledge on HPV and the HPV vaccination especially within minority communities can also increase vaccination rates, and studies should address myths and misconceptions when it comes to vaccinations and sexual health.

Some limitations of this review are the exclusions made. Many articles were found that tailored to male vaccination uptake, and these were excluded since this review solely focused on females. However, since males can also have complications due to HPV and they are carriers of the virus, it may be important to look into ways to increase male vaccination rates for future work. Another limitation of this study was the limited amount of theories used. For future research, it would be insightful to look at other types of behavior change theories as well. It An Assessment of Theory and Practice 25

might also be fruitful to extend the analysis to studies outside the United States. In this review,

only studies that took place within the United States were assessed.

Implications and Future Direction

Although this literature review was not able to find a definite answer to which theory is

best used to increase intention to vaccinate or vaccination rates it does pave the way for future

research. The review was able to show that as of now the HBM and TPB are the standards for

understanding behaviors that will increase vaccination rates or intention to vaccinate. For future

research it would be best to set up a comparison study that would compare the theories within 1

intervention design to test the same outcomes.

Increasing HPV vaccination uptake is important to lower HPV related cancers and

mortalities rates not just within the United States, but worldwide. Cervical cancer has been seen

as one of the leading causes of death globally. Evidence has shown that theory-based

interventions can increase the intervention’s effectiveness. Behavior change theories such as the

ones assessed in this literature review have shown to be effective. Most of the studies mentioned

that HPV disproportionately affects minority groups. Tailoring culturally appropriate

interventions to individuals who are at most at risk can decrease the HPV and cancer rates within

this group. This can be done by making interventions relevant to the participants and in a

language that is understandable to the targeted participants. This analysis can help public health

officials see what barriers they can address in order to lower the amount of HPV cases. Although

this study did not look into global HPV rates, it can shed light on theory-based interventions.

Applying universal theories to design HPV interventions can help to identify and overcome An Assessment of Theory and Practice 26 barriers that other countries face in increasing vaccination uptake. Understanding which theories are most effective in different cultural contexts might help to increase vaccination rates globally.

An Assessment of Theory and Practice 27

References Agénor, M., Peitzmeier, S., Gordon, A. R., Haneuse, S., Potter, J. E., & Austin, S. B. (2015). Sexual orientation identity disparities in awareness and initiation of the human papillomavirus vaccine among US women and girls: a national survey. Annals of Internal Medicine, 163(2), 99-106

Araldi, R.P., Sant’Ana, T.A., Modolo, D.G., de Melo, T.C., Spadacci-Morena, D.D., Stocco, R.D., Cerutti, J.M., & de Souza, E.B. (2018). The human papillomavirus (HPV)-related cancer biology: An overview. Biomedicine & Pharmacotherapy, 106, 1537-1556. Brawner, B. M., Baker, J. L., Voytek, C. D., Leader, A., Cashman, R. R., Silverman, R., ... & Frank, I. (2013). The development of a culturally relevant, theoretically driven HPV prevention intervention for urban adolescent females and their parents/guardians. Health Promotion Practice, 14(4), 624-636. Brianti, P., De Flammineis, E., & Mercuri, S. R. (2017). Review of HPV-related diseases and cancers. New Microbiolica, 40(2), 80-5. Center for Disease Control (2017a). STDs in adolescents and young adults. Sexually transmitted disease surveillance 2017. Bethesda, MD: Center for Disease Control and Prevention. Retrieved from https://www.cdc.gov/std/stats17/2017-STD-Surveillance- Report_CDC-clearance-9.10.18.pdf Center for Disease Control (2017b). HPV and men--CDC fact sheet. Bethesda, MD: Center for Disease Control and Prevention, July 2017. Retrieved from https://www.cdc.gov/std/hpv/HPVandMen-FS-July-2017-print.pdf Conner, M., McEachan, R., Lawton, R., & Gardner, P. (2017). Applying the reasoned action approach to understanding health protection and health risk behaviors. Social Science & Medicine, 195, 140-148. doi:10.1016/j.socscimed.2017.10.022 Ellis, E. M., Ferrer, R. A., & Klein, W. M. (2018). Factors beyond lack of knowledge that predict “I Don’t Know” responses to surveys that assess HPV knowledge. Journal of Health Communication, 23(10-11), 967-976.

Gerend, M.A. & Shepherd, J.E. (2012). Predicting human papillomavirus vaccine uptake in young adult women: Comparing the health belief model and theory of planned behavior. Annals of Behavioral Medicine, 44(2), 171-180. doi: 10.1007/s12160-012-9366-5

Jones, K. A., & Miller, E. (2016). Associations between condom attitudes, STI diagnosis and treatment, condom use, and non-condom contraceptive use. Journal of Pediatric and Adolescent Gynecology, 29(2), 204

Lopez, R., & McMahan, S. (2007). College women’s perception and knowledge of human papillomavirus (HPV) and cervical cancer. Californian Journal of Health Promotion, 5(3), 012-025. An Assessment of Theory and Practice 28

McBride, Kimberly R., & Singh, Shipra. (2018). Predictors of Adults' Knowledge and Awareness of HPV, HPV-Associated Cancers, and the HPV Vaccine: Implications for Health Education. Health Education & Behavior, 45(1), 68-76. Mullins, T. L. K., Zimet, G. D., Rosenthal, S. L., Morrow, C., Ding, L., Huang, B., & Kahn, J. A. (2016). Human papillomavirus vaccine-related risk perceptions and subsequent sexual behaviors and sexually transmitted infections among vaccinated adolescent women. Vaccine, 34(34), 4040-4045. National Council for Infectious Diseases (2014 August). Call to action: HPV vaccination as a public health priority. Bethesda, MD: National Foundation for Infectious Diseases. Retrieved from http://www.adolescentvaccination.org/professional-resources/hpv- resource-center/hpv-call-to-action.pdf Serrano, Brotons, Bosch, & Bruni. (2018). Epidemiology and burden of HPV-related disease. Best Practice & Research Clinical Obstetrics & Gynaecology, 47, 14-26. Sharma, M., Branscum, P. W., & Atri, A. (2014). Introduction to Community and Public Health. San Francisco, CA: Jossey-Bass. Skinner, C.S., Tiro, J., & Champion, V.L. (2015). The health belief model. In K. Glanz, B.K. Rimer, & K. Viswanath (Eds.,), Health behavior: Theory, research, and practice (pp.75-94). Hoboken, NJ: John Wiley & Sons.

Van Dyne, E. A., Henley, S. J., Saraiya, M., Thomas, C. C., Markowitz, L. E., & Benard, V. B. (2018). Trends in Human Papillomavirus-Associated Cancers - United States, 1999-2015. Morbidity and MortalityWeekly Report, 67(33), 918–924. doi:10.15585/mmwr.mm6733a2

Williams, W. W., Lu, P. J., O’Halloran, A., Bridges, C. B., Kim, D. K., Pilishvili, T., Hales, C.M.,& Markowitz, L. E. (2015). Vaccination coverage among adults, excluding influenza vaccination—United States, 2013. MMWR. Morbidity and mortality weekly report, 64(4), 95.

An Assessment of Theory and Practice 29

Figure 1. Flow Chart of Articles Included in Systematic Literature Review.

Diagram shows potentially relevant articles, exclusions and the final article count. The relevant article count was 117. When excluding the articles by abstract relevance the total remaining was 117. Further exclusion by gender to include only articles containing females made the count 81. Exclusion by region which removed articles that were not based within the USA made the count 24. Finally, exclusion by age range resulted in 15 relevant articles.

An Assessment of Theory and Practice 30

Appendix

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Developm The Cross- N=418 TPB is an Pamphlet Latina ent of a purpose of Sectional effective interventio women are Cost- this article Study: 418 way to n brought a at an Effective was to Hispanic measure cost- increased Educationa access the mothers the effective risk for l Tool to (1) clarity received mother’s way to cervical Promote of educationa attitude teach cancer Acceptanc educationa l material towards Hispanic related to e of the l material informing vaccinatio mother's HPV and HPV informing them about n and it about HPV creating Vaccinatio Hispanic HPV, will serve and HPV health n by mothers Cervical as an vaccinatio educationa Hispanic about cancer, and important n. l material Mothers, HPV, the HPV predictor Changing in their Journal of cervical vaccine. of her the native Communit cancer and They took intention to mother's language is y Health the HPV an vaccinate attitude the best vaccine, anonymou her about the way to (2) s survey, children in HPV increase determine 91% the future. vaccinatio vaccinatio vaccinatio understood n is best n uptake in Another n most info, when for them finding acceptabili 77% had a trying to and was that ty, (3) vaccine increase increase younger identify acceptance vaccinatio intention to women predictors . Language n rates for vaccinate and of vaccine barrier was their children. mothers acceptance an issue so children. who in an the survey declined underserve and vaccinatio d health educationa ns because setting. l materials of safety were made and in Spanish. autonomy The theory concerns An Assessment of Theory and Practice 31

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns of planned were also behavior less likely was used to permit in this the HPV study. vaccinatio n for their children. Relevant personal gynecolog y events didn't influence vaccine uptake which contrast the HBM. Views on The Mixed- N=50 Survey and Parental TPB Human Purpose of Method focus influence constructs Papillomav this study Study: 50 groups is a big used to irus was to Adolescent found ta when determine Vaccinatio explore s recruited profound determinin awareness n: A attitudes from lack of g HPV of these Mixed- and beliefs community knowledge vaccinatio attitudes Methods about HPV -based within this n uptake. and beliefs Study of vaccinatio organizatio group Some can assist Urban n among ns (age 14- about HPV barriers for providers Youth, urban, 18). 98% and HPV vaccinatio and health Journal of economica African vaccinatio n uptake ofﬁcials by Communit lly American, n. HPV include informing y Health disadvanta 52% vaccinatio lack of speciﬁc ged female. n awareness, interventio adolescent Participant acceptabili anticipated ns to s using the s were ty relied a side increase framework surveyed lot on effects, vaccine from the and placed and uptake. An Assessment of Theory and Practice 32

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns theory of in focus parental concerns planned groups influence with behavior. with vaccine questions safety. made using the TPB to understand vaccine acceptance and uptake.

A Quality The Cohort N=53 The This article HBM Improvem purpose of study with interventio showed constructs ent this study a Quasi n that the can be Initiative was to Experimen (prospectiv HBM was used to to Increase assess if an tal design: e group) successful address HPV evidence Parents had a 75% in barriers to Vaccine based were increased increasing vaccinatio Rates educationa recruited vaccinatio the n uptake Using an l brochure and placed n uptake vaccinatio such as Educationa and into two while the n uptake in dangers l and reminder separate control the associated Reminder system can groups: group only interventio with Strategy increase historical had a n group. vaccine, With HPV control 24.1% susceptibili Parents of vaccinatio parent increased ty, Preteen n uptake group had vaccinatio likelihood Girls, and dose 29 parents n uptake. of HPV Journal of completion and an The infection, Pediatric . Study interventio completion severity of Health used the n group rate in the dangers Care HBM n=24. An prospectiv related to constructs. educationa e group cervical l brochure was 62.5% cancer. that was compared When creased to 6.9% in educationa An Assessment of Theory and Practice 33

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns with HBM control l material constructs group. addresses was given these to parents barriers in the there is an interventio increase in n group in vaccinatio order to n uptake as measure if seen in this parents study. would increase in vaccinate vaccinatio their n daughters. There was a 6-month check-up and a 13- month check-up. Design and The This study Focus Providing TPB was It is efficacy of purpose of had two group educationa used to see important a this study different total: l materials the to multilingu was to component N=83. in the attitudes, incorporate al, create a s all language normative culturally

multicultur culturally tailored to of the beliefs, appropriate al HPV appropriate educating Video parents can and materials vaccine educationa Korean distributio increase intention to when education l material and Latin n total their vaccinate. education interventio to educate parents on N=708. knowledge This theory minority n, Journal Hispanic HPV and and helped groups. of and HPV vaccinatio create Communic Korean vaccinatio n uptake informatio ation in parents on ns by especially nal Healthcare HPV and making a in children material HPV culturally who are at that helped vaccinatio appropriate higher risk parents n using the educationa of HPV decide to An Assessment of Theory and Practice 34

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns TPB as a l video that (Latino vaccinate model. is in their and children. language. Korean). 42 Latino The study parents and saw an 41 Korean increase in parents the were put in knowledge 6 different parents focus received groups (3 that Spanish/En allowed glish, 3 them to Korean/En make an glish). informed These decision focused when groups choosing if followed they the theory should get of planned their behavior children model to vaccinated. gather informatio n on how to educate other parents. Then, the video was distributed to 708 Latino and Korean parents to assess their knowledge An Assessment of Theory and Practice 35

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns after watching the video. Knowledg e was tested using a pre-test and post- test.

Social This Mixed- N=34 TPB is a Barriers to More Cognitive study’s Method good HPV should be and purpose is study: 34 framework vaccine done in Clinical to increase sexually to assess initiation order to Factors knowledge active the were increase Associated and participant intention to identiﬁed, vaccinatio with HPV vaccinatio s ages 13- vaccinate and n rates and Vaccine n rates 26 were among evidence intent to Initiation among assessed economica supports vaccinate Among economica with lly use of the among Urban, lly urban questionna disadvanta TPB to economica Economica disadvanta ires using ged youth. guide lly lly ged youth TPB as a The study programs disadvanta Disadvanta ages 13- model. found that to promote ged youth. ged 26. These attitudes, urban, Women, questions norms, and economica Journal of looked at perceived lly Obstetric, the control disadvanta Gynecolog attitudes, were big ged young ic & norms, influencers women’s Neonatal perceived on starting intent to Nursing control, the HPV begin the and vaccinatio HPV intention to n. Tobacco vaccine. receive a usage was HPV also an vaccinatio influencer. An Assessment of Theory and Practice 36

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns n. The study found what barriers and what behaviors lead to vaccinatio n intention.

Using the To assess The study N=217 Results TPB is a The article Theory of the looked at show that good suggests Planned influences how mothers’ theory to that Behavior of mother's attitudes, intentions predict mothers to Predict intentions subjective to intentions alone are Mothers’ to norms, vaccinate and not the Intentions vaccinate perceived are not perceived only to their behavioral overwhelm control for influences Vaccinate daughters control, ing. vaccinatio for Their using the may Attitudes n intention to Daughters TPB. influence were the intentions. vaccinate. Against intention to strongest Perceived School HPV, The vaccinate predictor behavioral nurses can Journal of against of control also School HPV. A mothers’ was a influence Nursing survey was intentions problemati intention to distributed to c vaccinate. to 10 vaccinate. construct, mothers Subjective as the and based norms measures on their were the for this feedback only other construct the survey predictor did not was of hold revised. intention in together in The survey this model. the factor was then Mothers analysis An Assessment of Theory and Practice 37

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns sent to did not 1,207 have a lot women in of a intention to randomize vaccinate d sample alone of women therefore with the study children suggest ages 9-15 other in a rural influences Midwest that can be state. 306 used. women completed or partially completed the survey and out of these surveys 217 were used in the study. Predicting The A survey N=739 The Both TPB Attitudes, Human purpose of was sent to findings and HBM perceived Papillomav this study women in indicated can be behavioral irus was to a that TPB used to control, Vaccine compare southeaster consistentl increase and Uptake in two classic n y vaccinatio subjective Young theories of university. outperform n uptake. norms are Adult health 2,782 ed the TPB good Women: behavior— women HBM. constructs constructs Comparing the Health responded Predictors have to use the Health Belief to the to shown to when Belief Model survey but vaccinatio better trying to Model and (HBM) only 1,612 n uptake increase increase Theory of and the were was An Assessment of Theory and Practice 38

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Planned Theory of eligible. subjective vaccinatio vaccinatio Behavior, Planned After norms, n uptake. n uptake. Annals of Behavior further self- Behavioral (TPB)—in screening efficacy, Medicine their 739 and prediction women vaccine of human were cost. The papillomav eligible. theories irus (HPV) The had some vaccinatio women overlappin n uptake. were split g ideas. in 3 Some of groups, these (gain theory frame constructs N=250 were which similar. viewed a video og benefits of getting vaccine. loss frame N=243 which viewed a video of cost of not getting the vaccine and no frame info N=246). After groups finished videos, they An Assessment of Theory and Practice 39

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns received educationa l material on HPV and a post test. 10 months follow up to see if they received HPV. There was a 10 month follow up to see if the women had a vaccine. HPV The Cross- N=296 The It is Latina Vaccine purpose of sectional findings important women are Awareness this study study uses indicated to have at an , Barriers, is to add to a mixed that cues to providers increase Intentions, the methods action discuss risk for and Uptake literature approach (HBM) HPV and HPV and in Latina documenti incorporati was an HPV physician Women, ng factors ng the important vaccinatio recom- Journal for associated HBM and construct n with mendation Immigrant with HPV TPB in dictating Latino of vaccine Minority vaccinatio constructs vaccinatio women can Health n uptake to create a n uptake. It who are at increase such as phone was found heightened vaccinatio vaccinatio survey that that risk of n uptake. n barriers, was provider developing reasons for conducted recommen HPV and vaccinatio to 2,193 dation was HPV n, intention Latina a big factor related to women in diseases An Assessment of Theory and Practice 40

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns vaccinate, living in increasing such as and Dane vaccinatio cancer. vaccinatio County n uptakes. n uptake in Wisconsin. a sample Out of the of Latinas. initial count only 296 women participate d. The survey was done to assess barriers for vaccinatio n uptake. Many women knew about HPV in the survey. Hip Hop, The This study The Education Sending Health, purpose of uses findings materials health and this study constructs indicate should be promotion Human is to use from the that culturally messages Papilloma hip-hop Theory of culturally appealing via cell Virus culture to Reasoned appropriate and phones or (HPV): promote Action to methods appropriate other Using HPV create a for health . Some electronic Wireless vaccinatio program promotion limitation devices is Technolog n uptake that infuses are for this a good y to among hip-hop important study were way to Increase African culture and when that educate HPV American technology trying to technology younger Vaccinatio women to reach increase accessibilit women to n Uptake, and other women vaccinatio y must be increase An Assessment of Theory and Practice 41

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns The minority and n uptake. measured vaccinatio Journal for groups increase Theory of before n rates. Nurse using cell vaccinatio Reason implement Practitione phone n uptake. Action was ation of rs technology Health used for project. . promotion these messages findings with hip- and proved hop music successful. was messaged to cell phones with informatio n regarding HPV. The constructs used were knowledge of HPV, attitudes and beliefs, personal characterist ics, and subjective norms have direct effect on HPV vaccine uptake. An Assessment of Theory and Practice 42

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Testing a The This study N=428 This study TRA and If parents Model for purpose of used both found that HBM can believe Parental this study the HBM parents both be that HPV Acceptanc was to test (perceived were more used to vaccinatio e of a model threats, likely to assess n causes Human that perceived vaccinate vaccinatio side effects Papillomav predicts barriers, older n intention. or sexual irus intention to perceived children The disinhibitio Vaccine in vaccinate benefits, than biggest n, public 9- to 18- and and cues to younger barriers are health Year-Old vaccine action) and children. If parents’ officials Girls: A status. The TRA they thoughts should Theory- model (beliefs believed about concentrat Guided includes and their vaccinatio e on Study, constructs normative daughters n safety. educated Journal of from two beliefs) in were the public Pediatric theories: a survey to susceptible on these Nursing the health assess to HPV barriers. belief parents’ their model (HB intentions vaccinatio M) and to n intention the theory vaccinate increased. of their Some reasoned daughters. barriers action (TR Parents included A) were worries recruited about side via emails. effects, The study safety of targeted vaccine, parents and with girls worries ages 9-18 about the that can vaccine read causing English sexual and have disinhibitio internet n. An Assessment of Theory and Practice 43

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns access in the Brooklyn area. Recruitme nt was in 2009. 495 people replied to the survey but only 428 people were parents. Of these individuals 105 exited before the survey ended, 218 had not vaccinated their children and 107 had already vaccinated. An Assessment of Theory and Practice 44

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Parental The This study N=84 This study Physician It is Response purpose of looked at observed advice and important to Human this study the HBM significant parental to address Papillomav was to and the differences beliefs are barriers or irus examine TPB to in important issues Vaccine parental examine vaccinatio to consider parents Availabilit response to parents’ n of when have with y: Uptake the knowledge daughters promoting the HPV and quadrivale and beliefs age, adolescent vaccinatio Intentions, nt HPV about HPV physician HPV n in order Journal of vaccine vaccinatio recommen vaccine to increase Adolescent approximat n as well dation, uptake. vaccine Health ely 2 years as HPV uptake. after its correlates vaccine release in of HPV knowledge 2006. vaccine , and uptake and vaccine intentions attitudes. to The study vaccinate found children. parents Recruitme who were nt was more done with knowledge surveys in able about examinatio HPV were n rooms more likely tailored to to parents vaccinate. with at Parents least 1 knowledge child under typically the age of came from 18 television attending 1 ads or out of 4 media. 1/2 pediatric of parents clinics in said the An Assessment of Theory and Practice 45

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns the HPV Southeaste vaccine rn U.S. A would total of 84 have to be surveys on the were market for completed at least 3 between years in Jan-June order for 2008. them to vaccinate their children. Parents are more likely to vaccinate teens than preteens. The This article This study N=131 Participant Self- Public Influence explored looked at s in the efficacy is health of Self- the media (in high self- a big individuals efficacy in influences the form of efficacy predictor should Medical of medical a medical group had when it focus on Drama drama drama) and a bigger comes to media as a Television viewing on its effect intention to intentions form of Programmi health on self- vaccinate to increasing ng on behaviors, efficacy. vs those in vaccinate. HPV Behaviors emotions, The study the low The Social vaccinatio and and used the self- Cognitive n uptake. Emotions examined SCT and efficacy Theory is a that the role of looked at group. The good way Promote self- how a high article also to asses Cervical efficacy in self- found that self- Cancer medical efficacy media is a efficacy. Prevention, drama characteriz good way American ation of to promote Journal of disease positive An Assessment of Theory and Practice 46

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Health programmi prevention health Behavior ng. can behaviors influence since vaccine media has uptake. been 131 studied as participant an s were influential recruited tool in and split in changing 2 groups behavior. (high self- efficacy and low- self efficacy). It was hypothesis that the group exposed to a high self- efficacy would have a higher intention to receive cervical cancer screenings and HPV vaccinatio n uptake. The groups watched 6 min clips of a Grey’s An Assessment of Theory and Practice 47

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Anatomy show that dealt with cervical cancer. The third video was manipulate d to either have a high self- efficacy with statements such as: getting cervical cancer testing and prevention is cost effective and fast vs low self- efficacy which had statements such as: it is expensive getting cervical cancer screenings and HPV vaccinatio ns. Intentions An Assessment of Theory and Practice 48

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns to vaccinate or have screenings were determined with pre and post- test.

HPV This Vaccinatio N=36 The three Out of this It is Vaccine study's n rates major study 3 important and Latino purpose among findings primary for Latinos Immigrant was to Latino were: 1. ways to to have Parents: If explain the children there was a increase access to They Offer barriers are low lack of vaccinatio health care It, We Will that Latino although awareness n rates in order for Get It, immigrant the cancer and among them to be Journal of parents rates are knowledge Latinos able to get Immigrant face when disproporti of HPV are:1. vaccinatio Minority it comes to onately and HPV increase ns they Health HPV higher for vaccine 2. population need. vaccinatio Latinos participant knowledge n. when it s showed a regarding comes to high rate HPV and HPV. This of self- HPV study efficacy or vaccine. 2. recruited confidence encourage 36 Latino that they Latino immigrant can get population parents and their child to seek the placed vaccinated vaccine for them into 5 3. a major their separate barrier eligible An Assessment of Theory and Practice 49

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns focus discovered child. 3. groups that was lack of increase had 5-10 provider provider participant recommen recommen s/group. dation. dation for The focus the groups vaccine. were Access to conducted healthcare in Spanish may also and used be a constructs barrier. from the Promiscuit HBM, y from TPB, SCT. vaccine Participant was not a s were barrier surveyed within this before group as group and opposed to debriefed other after with studies. informatio n regarding HPV. They were asked questions regarding their knowledge , attitudes, beliefs, and barriers regarding HPV Vaccine. The An Assessment of Theory and Practice 50

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns parents were recruited from NYC neighborho ods that had a high concentrati on of Latino immigrants . Transcripti ons were created and analyzed for recurring themes. Using a The This study N=279 RAA is a Theory is a Women Reasoned purpose of looks at a good good way HPV Action this study mixed- theory to to predict intentions Approach was to theory use in intentions should be to examine identify approach accessing to assessed in US college underlying to see what intention to vaccinate order to women’s factors the factors get the against see what intention to influencing influence HPV HPV for barriers are get the college HPV vaccine. women. keeping HPV women’s vaccinatio Since this More them from vaccine, intention to n intention. theory is physicians getting Health get the Recruitme fairly knew should vaccinated. Education HPV nt was this study initiate Journal vaccine via done at a also shows discussion developing midwester it utility. of an n USA Physician regarding instrument college. recommen HPV. using the 310 dation was Reasoned questionna An Assessment of Theory and Practice 51

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Action ires were not seen as Approach distributed a barrier (RAA). and 290 The HBM came back. constructs Of those were also only 279 used. were analyzed. Questions were based on RAA and HBM constructs that assessed demograph ic variables, preventativ e health behaviors, and knowledge and beliefs about HPV. The This study This study N=141 Adolescent The theory Since Developm purpose had two s: 64% of planned children ent of a was to different have heard behavior are having Culturally make a 2- types of about the was used sexual Relevant, skill based interventio HPV to assess encounters Theoretical interventio ns. The vaccine. why at a much ly Driven n curricula participant They had vaccinatio younger HPV aimed to s recruited negative n rates are age, it is Prevention increase were either attitudes of low in important Interventio HPV 13-18 vaccines' urban low to attempt n for prevention (total of 93 inability to income to get them Urban and participant prevent all African vaccinated An Assessment of Theory and Practice 52

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns Adolescent vaccinatio s) and HPV American before they Females n among parents/car strains. It girls. It have their and Their low egivers was also was first sexual Parents/Gu income (total of 48 founded indicated contact. ardians, urban participant that most that there Health adolescent s). The participant needs to be Promotion females TPB was s had their a rise in Practice ages 9-18 used to first sexual knowledge in a create a encounter about HPV Philadelphi survey. before age and HPV a One of the 14 vaccine. It neighborho interventio is also Parents: od. ns was important 81.3 % interview to increase have heard structured skills for of HPV to assess parents and vaccines participant teens to but are s attitudes talk to concerned and their about the beliefs. physicians safety of The other about the the interventio HPV vaccine. n was vaccine. focus groups that also were structured using TPB. The results of these interviews and focus groups were recorded and transcribed . There An Assessment of Theory and Practice 53

Article Purpose Methodolo Sample Primary Conclusion Public gy/ Type Size Results s Health of Study Implicatio ns were 6 goals for these interventio ns. A post- test was also done.