Theory of Planned Behavior-based Correlates of HPV Vaccination Intentions and Series Completion among University Students in the Southeastern United States Hannah Priest Catalano, Keith Richards, and Katherine Hyatt Hawkins Abstract of anogenital warts, recurrent respiratory papillomatosis, and cancers of the anus, cervix, oropharynx, penis, vagina, and This study tested a theory of planned behavior (TPB)-based vulva (CDC, 2017b). Individuals who have received a positive model in predicting human papillomavirus (HPV) vaccination HPV diagnosis may also experience adverse psychosocial intentions and series completion among university students. outcomes including stress, anxiety, depression, anger, guilt, A nonexperimental, cross-sectional design was utilized with frustration, and poor health-related quality of life (Daley et al., a convenience sample of 281 university students, including 2010; Daley et al., 2012; Dominiak-Felden et al., 2013). 40.9% nonvaccinees, 19.6% vaccine initiators, and 39.5% Young adults (20–24 years) have the highest HPV series completers. The stepwise multiple regression model prevalence rates (53.8%) of any age group in the United revealed that attitude and subjective norm were significant States (Satterwhite et al., 2013). Thus, university-age students predictors of behavioral intention and collectively explained are a high-risk population for becoming infected, and HPV 60% of its variance. The logistic regression model identified is currently the most common STI among this population behavioral intention and gender as significant predictors of (Fontenot, Fantasia, Sutherland, & Lee-St. John, 2016). There series completion. Findings suggest that: (a) nonvaccinees is no cure for HPV, but the HPV vaccine protects against the with more positive attitudes and greater subjective norm have most common strains that contribute to genital warts and a greater intentions to complete the series, and (b) college females variety of cancers caused by HPV infection (CDC, 2017a). and those who have greater intentions to get vaccinated have Prior to the implementation of the HPV vaccination, an greater odds of completing the series. For those not vaccinated, estimated 350,000 men and women were affected by genital practitioners should aim to increase students’ positive attitudes warts each year in the United States (CDC, 2017a). Each year and perceived social pressure regarding series completion. an estimated 17,600 women and 9,300 men in the United States Health educators should aim to develop HPV-related programs are affected by cancers caused by HPV (CDC, 2017a). that target college men and increase students’ behavioral Three HPV vaccines have been approved by the United intention by applying implementation intention strategies that States Food & Drug Administration to protect against HPV encourage series completion. infection: a bivalent vaccine (HPV2, Cervarix), a quadrivalent vaccine (HPV4, Gardasil), and a 9-valent (HPV9, Gardasil Keywords: HPV vaccination, university students, theory of 9) vaccine (U.S. Food & Drug Administration, 2014, 2015a, planned behavior 2015b). All three of the HPV vaccines protect against HPV types 16 and 18, which cause most HPV-associated cancers Introduction (Petrosky et al., 2015). The quadrivalent and 9-valent vaccines also offer protection against HPV types 6 and 11, which cause Human papillomavirus (HPV) is a significant public the majority of genital warts cases (Petrosky et al., 2015). The health burden. HPV is the most common sexually transmitted 9-valent vaccine provides additional protection against types infection (STI) in the United States, with an overall prevalence 31, 33, 45, 52, 58, which cause various HPV-associated cancers of 45.2% among adults aged 18-59 (Centers for Disease (Petrosky et al., 2015). Effective since the end of the year in Control and Prevention [CDC], 2017a; McQuillan, Kruszon- 2016, the 9-valent vaccine is the only HPV vaccine distributed Moran, Unger, & Paulose-Ram, 2017). HPV is a known cause in the United States (CDC, 2016). The United States of America’s Advisory Committee on * Hannah Priest Catalano, PhD, CHES, Assistant Professor, Immunization Practices (ACIP) recommends a 2-dose HPV School of Health and Applied Human Sciences, University vaccination series for 11 or 12 year old girls and boys (Meites, of North Carolina Wilmington, Hanover 119C, 601 S. Kempete, & Markowitz, 2016). Findings from rigorous College Road, Wilmington, NC 28403; Phone: 910-962- scientific studies have consistently demonstrated that the 7768; Email: [email protected]; Fax: 910-962-7073; HPV vaccine is safe for this age group and initiates a stronger ESG Chapter Membership: National Member at Large immune response among younger adolescents compared to Keith Richards, PhD, Assistant Professor, School of older adolescents (Markowitz et al., 2014; Petrosky et al., 2015). Communication, East Carolina University, 102 Joyner Consequently, the 2-dose HPV vaccination series is approved East, Greenville, NC 27858; Phone: 252-737-4641; for use among 9-14 year old girls and boys (Meites et al., 2016). Email: [email protected] The ACIP recommends a 3-dose catch-up HPV vaccination Katherine Hyatt Hawkins, MA, Graduate Teaching Assistant, for females ages 15-26 and males ages 15-21 who have not George Mason University, Department of Communication, received the vaccine (Meites et al., 2016). Males ages 22-26 Fairfax, VA 22030; Phone: 614-935-4364; Email: may also be vaccinated. Although the HPV vaccine is ideally [email protected] recommended for younger adolescents, older adolescents and * Corresponding Author young adults who fall within the catch-up window still reap considerable benefits from the vaccination (Markowitz et al., Fall 2017, Vol. 49, No. 2 The Health Educator 35 2014). Traditional college-age students are at high risk for HPV measured HPV vaccination intentions or vaccination status infection because the majority are currently sexually active using ambiguous terms, not specifying the number of doses (American College Health Association [ACHA], 2017). A total in the series or a time-frame. Additionally, all except one of of 27,787 undergraduate students were included in the Fall 2016 these studies (Catalano et al., 2017) did not operationalize National College Health Assessment (NCHA) II Reference constructs based on Ajzen’s (2006) recommendations for Group analyses (ACHA, 2017). The NCHA II revealed that construct measurement. Therefore, further testing of the TPB nearly two thirds (65.8%) of undergraduate students had oral, in predicting college students’ HPV vaccination intentions, vaginal, or anal sex with one or more partners within the last initiation, and series completion is needed. 12 months. An estimated 46% of college undergraduates had This study addresses a gap in the literature by assessing vaginal intercourse within the last 30 days, 43.4% had oral sex rates of HPV vaccine initiation and series completion among within the last 30 days, and 5.2% had anal sex within the last university students. Further, this study tests a theory of planned 30 days (ACHA, 2017). HPV vaccination rates for college-age behavior-based model in predicting HPV vaccination intentions students fall considerably below the Healthy People 2020 goal and series completion among this population. The theory of of 80% coverage for adolescent males and females (Office of planned behavior posits that an individual’s attitudes toward Disease Prevention and Health Promotion, 2017). Based on a specific behavior, perceived social pressure to engage in that findings from the Fall 2016 NCHA II, less than half of college behavior (subjective norm), and perceived behavioral control men (47%) reported being vaccinated against HPV and less than to engage in that behavior predict one’s behavioral intention two thirds (60%) of college women reported being vaccinated to perform the behavior (Ajzen & Driver, 1991). Behavioral (ACHA, 2017). However, it is not possible to discern how intention is theorized to be the most immediate precursor to many doses of the HPV vaccine the respondents completed performance of a given behavior (Ajzen & Driver, 1991). In based on the way the survey item was constructed. The item this study, the behavior of interest is receipt of three doses of stem is written as follows “Have you received the following the HPV vaccine within a 12 month time-frame. vaccinations (shots): Human Papillomavirus/HPV (cervical The purpose of this study was to test a theory of planned cancer vaccine)?” Six vaccines are listed in a column below behavior-based model in predicting HPV vaccination intentions the stem statement, including “human papillomavirus/HPV and series completion among university students. Results from (cervical cancer vaccine)”. “Yes”, “no”, and “I don’t know” are this study can contribute to health education efforts surrounding provided as response options for each vaccine (ACHA, 2017, HPV vaccination. Identification of modifiable intrapersonal- p. 41). Therefore, the HPV vaccination rates could have been level, theoretical factors that influence university students’ inflated since respondents who selected “yes” may have only decision making regarding HPV vaccination can be used for had one dose of the HPV vaccine (American College Health the design of effective health education interventions. Association, 2017). University students are an important population for encouraging catch-up HPV vaccine uptake Methods due to less than optimal vaccination rates and participation