Assessing the Efficacy of the 3R (Reframe, Reprioritize, and Reform) Communication Model to Increase HPV Vaccinations Acceptance in Ghana: Community-Based Intervention

"An intervention utilizing the 3R communication model was effective in increasing parental and adolescent knowledge, attitudes, and confidence toward the HPV vaccination, as well as intention of HPV vaccination acceptance."

In 2013, Ghana pilot-tested human papillomavirus (HPV) vaccination in collaboration with the Global Alliance for Vaccines and Immunizations (GAVI) in 4 districts. However, Ghana's national immunisation technical advisory group (NITAG) has yet to recommend an introduction of the HPV vaccine to its national immunisation schedule, and it is well documented that low- and middle-income countries (LMICs), such as Ghana, tend to have low HPV vaccination rates. Previous research suggests that logistical and attitudinal barriers contribute to low vaccinations in LMICs such as Ghana. This study describes the integration of a 3R (reframe, reprioritise, and reform) communication model with the theory of planned behaviour (TPB) to promote HPV vaccination among Ghanaian parents and their unvaccinated adolescents.

Brief details on the concepts studied:

• On the 3R model, information on HPV vaccination can be maximally persuasive depending on how the information is framed. HPV vaccination information can emphasise the benefits of taking action (i.e., a gain-framed appeal) or the costs of failing to take action (i.e., a loss-framed appeal). Several studies have pursued how the framing of a health message might affect people’s willingness to perform a particular behaviour.
• The TPB, which posits that behavioural intention is the most proximal determinant of social behaviour, can help explain intentions, attitudes, and perceived behavioural control for vaccination of parents and adolescents. This study determined whether the expected positive impact of the intervention on the parents' decision making for vaccination was explained by TPB constructs (behavioural intention, attitude, and behavioural control/self-efficacy) and knowledge.

To conduct the quasi-experimental (no control group) community-based intervention study, the researchers recruited parents/caregivers (hereafter referred to as caregivers) and their 12- to 17-year-old adolescents from 3 local churches in the Ashanti Region of Ghana. The researchers organised 6 intervention presentations on 6 different days: 3 presentations for the caregivers, and another 3 for the adolescents. Each group had 25-30 participants. Following each factual presentation about the vaccination and the HPV virus, the researchers used a loss-framed appeal throughout to guide all discussions (e.g., if you decide not to vaccinate, you will not feel the peace of mind that comes with knowing that your child is protected, or you are protected).

• Module 1 content covered reframing the conversations about the HPV vaccination as protection from cancer rather than sexually transmitted infections.
• Module 2 content covered reprioritising cervical cancer prevention as a healthcare priority for adolescents by creating awareness, building behavioural confidence, and reinforcing positive beliefs about HPV vaccination as a cancer prevention strategy.
• Module 3 content covered reforming the belief system by teaching ways for the participants to confront the barriers (e.g., stigma and belief about promoting promiscuity) to HPV vaccination and helping them to uncover the logical flaws/or misinterpretation of HPV vaccinations.

Participants completed baseline and post-intervention assessments based on a validated TPB instrument. A total of 170 participants including parents (n = 85) and adolescents (n = 85) provided evaluable data. Ninety-two percent of the parents and all the adolescents who participated in the study were females. The primary outcome was acceptance for vaccination (defined as the likelihood of parents accepting HPV vaccine for their adolescent in the next month or the likelihood of adolescent accepting vaccination in the next month).

Intervention effect on primary outcome:

• Parents and adolescents: After controlling for the baseline assessment, it was found that participants' likelihood of HPV vaccination acceptance was associated with their post-intervention self-confidence scores (adjusted odds ratio (AOR) = 1.19, 95% confidence interval (CI): 1.08, 1.30). In other words, for every one-unit increase in the post-intervention self-confidence scores, the odds of participants' intention for HPV vaccination acceptance increased by 19%. The participants' likelihood of HPV vaccination acceptance was associated with their post-intervention positive attitude scores (AOR = 1.09, 95% CI: 1.03, 1.10). Thus, for every one-unit increase in the post-intervention positive attitude scores, the odds of participants' intention for HPV vaccination acceptance increased by 9%.
• Parents only: For every one-unit increase in the intervention score of parents' confidence, the odds of a higher (vs. lower) likelihood of vaccine acceptance for their adolescents increased by 28% while holding baseline scores constant [AOR = 1.28 (1.09, 1.51)]. For every one unit increase in the intervention score of parents' positive attitudes, the odds of a higher (vs. lower) likelihood of vaccine acceptance for their adolescent increased by 21% while holding baseline scores constant [AOR = 1.21 (1.03, 1.43)]. For every one-unit increase in the intervention score of parents' negative attitudes, the odds of a lower (vs. high) likelihood of vaccine acceptance for adolescents increased by 15% while holding baseline scores constant [AOR = 1.15 (1.04, 1.28)].
• Adolescents only: For every one-unit increase in the intervention score of adolescents' confidence, the odds of a higher (vs. lower) likelihood of vaccine acceptance increased by 18% while holding baseline scores constant [AOR = 1.18 (1.04, 1.34)]. For every one-unit increase in the intervention scores of adolescents' positive attitudes, the odds of a higher (vs. lower) likelihood of vaccine acceptance increased by 7% while holding baseline scores constant [AOR = 1.07 (1.00, 1.16)].

The post-intervention results also indicated:

• A significant change in mean scores for knowledge about HPV vaccination for parents who had annual household income less than GHS 20,000 (~USD 2500), had no educational background, had less than a high school degree, and had an undergraduate degree, with increases by 16.78, 12.58, 11.77, and 12.40 points, respectively (p < 0.001).
• A significant change in the mean scores of parents with no educational background and those with income less than GHS 20,000 (~USD 2500) for their attitude toward HPV vaccination: Their mean scores increased by 14.00 and 15.83 points, respectively (p < 0.001).
• A significant change in the scores for the likelihood or intentions of allowing their adolescent to get vaccinated (p < 0.001) for male parents as well as those who had never married, those with annual household income less than GHS 20,000 (~USD 2500), and those with no health insurance. Scores of the intention to allow their adolescent to vaccinate for male parents increased by 3.14, for those were never married increased by 2.0, for those with income less than GHS 20,000 increased by 2.63, and for those with no health insurance increased by 2.61.

Overall, the 3R communication model was effective in influencing the participants' intentions for HPV vaccination acceptance. Participants' likelihood of HPV vaccination acceptance was associated with their self-confidence. Per the researchers, the in-person group presentation, moderate group size, and method of communication delivery have been shown to effective agents of change to improve knowledge and attitudes related to cervical cancer and HPV/HPV vaccination, along with the increased likelihood of intention to accept vaccination. This study, in conjunction with other studies assessing messaging type, found that communication programmes that focus on the individual benefit of vaccination are the most effective at increasing vaccine intention and uptake.

In conclusion: "These findings suggest that the 3R communication model, when used to guide intervention, has the potential to increase HPV vaccination uptake in Ghana. This information has important implications for the importance of education and addressing attitudes and perceptions when informing parents of HPV vaccination."