Designing and evaluating a health belief model based intervention to increase intent of HPV vaccination among college men: Use of qualitative and quantitative methodology A dissertation submitted to the Graduate School of the University of Cincinnati In partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY In the School of Human Services of the College of Education, Criminal Justice, and Human Services 2012 by Purvi Mehta MS, University of Cincinnati Committee Chair: Manoj Sharma, M.B.; B.S., MCHES, Ph.D Abstract Humanpapilloma virus (HPV) is a common sexually transmitted disease/infection (STD/STI), leading to cervical and anal cancers. Annually, 6.2 million people are newly diagnosed with HPV and 20 million currently are diagnosed. According to the Centers for Disease Control and Prevention, 51.1% of men carry multiple strains of HPV. Recently, HPV vaccine was approved for use in boys and young men to help reduce the number of HPV cases. Currently limited research is available on HPV and HPV vaccination in men. The purpose of the study was to determine predictors of HPV vaccine acceptability among college men through the qualitative approach of focus groups and to develop an intervention to increase intent to seek vaccination in the target population The study took place in two phases. During Phase I, six focus groups were conducted with 50 participants. In Phase II using a randomized controlled trial a HBM based intervention was compared with a traditional knowledge based intervention in 90 college men. In Phase I lack of perceived susceptibility, perceived severity of HPV and barriers towards taking the HPV vaccine were major themes identified from the focus groups. Participants for this phase and phase II were primarily single, heterosexual, about 20 years old, Caucasian males attending the University of Cincinnati. Phase II analysis was done for pretest/posttest and for pretest/posttest/follow-up. This was done due to a 17.8% retention rate at follow-up. Repeated measures of ANOVA indicated significant positive changes in the intervention group. Scores for knowledge and HBM constructs, perceived severity, perceived susceptibility, perceived benefits, perceived barriers, self-efficacy, and cues to action improved over time while no significant findings were made for the control group. Regression analysis was done for change scores at pretest/posttest, follow-up/pretest, and follow-up/posttest. No significant model was found for follow- up/posttest. Results from the pretest/posttest regression analysis indicated self-efficacy for taking the vaccine (p=0.000), perceived barriers (p=0.007), and perceived severity (p=0.004) were significant positive predictors of vaccine acceptability. The model had an adjusted R2 of 0.351which indicated that these three predictors accounted for 35.1% variance. HBM is a robust model to predict HPV vaccine acceptability in college men. Results from follow-up/pretest found perceived benefits (p=.004) held a significant positive relationship towards intent to vaccinate. The model had an adjusted R2 of 0.453, which indicated this predictor accounted for 45.3% variance regarding whether participants would take the vaccine. Overall, the intervention proved to be effective in creating positive change towards HPV vaccine acceptability. Some limitations had occurred, such as a low retention rate at follow-up, and differences between groups at baseline. Despite these issues, change in the intervention still occurred. This study indicates that more theory-based interventions are needed to increase HPV vaccination in college men. Acknowledgements This dissertation could not have been possible without the help of many faculty, family members, and close friends. First of all, I would like to thank my dissertation advisor, Dr. Manoj Sharma, for his help in securing a grant with Merck Pharmaceutical and his guidance in my career development as a researcher. I would also like to thank my academic advisor, Dr. Liliana Guyler, for her constant support, encouragement, and academic advice in this process. I would also like to thank my committee members, Dr. Wilson and Dr. Lee for their help in this endeavor. Most of all, I would like to thank my parents, especially my mother, for all the love, support and encouragement to get me where I am today. They stood by all the decisions leading up to the culmination of my degree, and pushed me when I thought I could not go any further. For all that they have taught me and done for me, I will never be able to show them the amount of gratitude I have for them. I would also like to thank my sister, Shruti Mehta, for making light of situations and reminding me to take it easy when things got stressful. I would also like to thank Chirag Mehta, Parag Mehta and Nyesia Mehta, for their support, laughter, and reminding me that there is light at the end of the tunnel. Outside of my family, I could not have made it without the support of my close friends. They have been there from the beginning and have helped me get through the thick and thin of things. It would not have been easy without them. Finally, I would like to thank, A.J.A., for his support, encouragement, and most of all, his reminder to have fun through it all. He, along with the rest, kept me sane in moments of insanity, and for that I am ever so grateful. Table of Contents List of Tables ……………………………………………………………………………….i List of Figures……………………………………………………………………………….v Chapter One: The Purpose…………………………………………………………………..1 Statement of the Problem…………………………………........................................13 Research Questions and Hypothesis………………………………………………...14 Operational Definitions……………………………………………………………...23 Delimitations………………………………………………………………………...24 Limitations…………………………………………………………………………...25 Assumptions………………………………………………………………………....25 Summary……………………………………………………………………………..25 Chapter Two: Review of Literature………………………………………………………....26 Human Papilloma Virus…………………………………………………………......26 Prevalence and Incidence……………………………………..……………………..27 Transmission and Duration ……………………………………………………….....28 HPV in Men ………………………………...……………………………………….30 Genital Warts….……………………………………………………………………...31 Cervical Intraepithelial Neoplasia……………………………………………………32 Cervical Cancer………………………………………………………………………33 Vaccines ……………………………….………………………………………….....37 HPV Vaccine…………………….…………………………………………………...41 HPV Vaccines in Men………………………………………………………………..44 Health Belief Model .………………………………………………………………...47 Applications of the Health Belief Model……………………………………………..49 Quantitative Designs………………………………………………………………….53 Quantitative Designs and the Health Belief Model…………………………………..54 Qualitative Designs………………………………………………………………...…57 Qualitative Designs and the Health Belief Model…………………………………….59 Summary………………………………………………………………………………61 Chapter Three: Methods………………………………………………………………………63 Design…………………………………………………………………………………63 Population and Sample……………………………………………………….….........69 Setting…………………………………………………………………………..…….71 Instrumentation…………………………………………………………………….....75 Confirmatory Factor Analysis…………………………………………………….….78 Researcher’s Role………………………………………………………………….....80 Data Collection………………………………………………………………….........80 Data Analysis………………………………………………………………………....82 Summary……………………………………………………………………………83 Chapter Four: Results………………………………………………………………………...84 Phase 1………………………………………………………………………………..84 Phase II……………………………………………………………………………….89 Assumption Testing…………………………………………………………………..95 Results for Repeated Measures ANOVA…………………………………………… 98 Regression Analysis…………………………………………………………………118 Summary……………………………………………………………………………..120 Chapter 5: Conclusions……………………………………………………………………..122 Phase I……………………………………………………………………………….122 Phase II………………………………………………………………………………124 Limitations…………………………………………………………………………...129 Implications for Practice……………………………………………………………..131 Future Recommendations……………………………………………………………...132 Summary……………………………………………………………………………….134 References…………………………………………………………………………………….135 Appendices Appendix A. List of panel of experts…………………………………………………..140 Appendix B. Survey………………………………………………………………….....141 Appendix C. Control Group Intervention…………………………………………........145 Appendix D. Experimental Group Intervention………………………………………..154 Appendix E. Informed Consent………………………………………………………...161 List of Tables Table 3.1 Reliability Coefficients (Cronbach’s alpha) for Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action, Self Efficacy, and Knowledge…………………………………………………………………………………….75 Table 3.2 Test-retest Reliability Coefficients for Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action, Self Efficacy, and Knowledge……..76 Table 4.1 A comparison of demographic and study variables between participants in the control (n=45) and experimental (n=45) groups at pre-test using an omnibus multivariate test………………………90 Table 4.2 A comparison of demographic and study variables between participants in the control (n=45) and experimental (n=45) groups at pre-test using separate univariate tests…………………………...90 Table 4.3 A comparison of demographic and study variables between participants in the control (n=45) and experimental (n=45) groups at pre-test using an omnibus multivariate test………………………91 Table 4.4 Distribution of Means and Standard Deviations for Health Belief Model Constructs, Knowledge, and Intent to Vaccinate for Control and Experimental Groups at Pre-test, Post-test, and Follow-up………………………………………………………………………………………………93 Table