Identifying Intervention Strategies to Improve HPV Vaccine Decision-making Using Behaviour Change Theory
Affiliation
University College Cork (Marshall, Fleming, Sahm, Moore); Mercy University Hospital (Fleming, Sahm)
Date
Summary
"It has been shown that using theory to understand the mechanisms of action of intervention strategies improves the effectiveness of interventions..."
It is well established that changing behaviour is complex, and a systematic approach is required to understand the factors that influence vaccine uptake. In general, providing information alone does not change behaviour. Behavioural change has been shown to be more effective if interventions are based on principles drawn from evidence and theories of behaviour and behavioural change. This study took a systematic approach to understand the factors that influence human papillomavirus (HPV) vaccine uptake by parents of adolescent girls in Ireland to define suitable behaviour change interventions that would support positive vaccine decision-making in the future.
In Ireland, the quadrivalent HPV vaccine has been offered to all girls in the first year of second-level schools (aged 12-13 years) by the national healthcare service. Since September 2019, the vaccine has been available to boys in Ireland as well, but at the time of this research, only girls were included in the vaccination programme.) As reported here, although HPV vaccines has been deemed highly safe and effective, unsubstantiated reports of safety signals for the vaccines remain a public concern. In Ireland, HPV vaccination rates of 87% were reported in 2014/2015 but plummeted to 51% in 2016/2017.
This study applies the Theoretical Domains Framework (TDF), the capability, opportunity, motivation model of behaviour (COM-B) system of behavioural change, and the associated Behaviour Change Wheel (BCW) as tools for describing the factors that influence the parental HPV vaccine decision, identified using 13 semi-structured interviews with parents (31% of whom had declined the HPV vaccine for their daughter). (See the paper for a full discussion of the TDF, COM-B, and BCW.)
The interviews revealed that the vaccine decision was complex and often involved interactions between several TDF domains - namely, knowledge, memory, attention and decision processes, social role and identity, beliefs about capabilities, optimism, beliefs about consequences, goals, emotion, environmental context, and resources and social influences. Participants consulted with other individuals, to varying degrees, while making their vaccine decision; all parents discussed the essential role of healthcare providers (HCPs) in vaccine decision-making.
Even those who chose to decline the HPV vaccine discussed how they had accepted paediatric and other adolescent vaccines. Apprehension was reported to be primarily due to circulating claims of chronic side effects (e.g., fatigue, seizures) associated with the vaccine. Participants recalled radio interviews, television documentaries, newspaper articles, and online information that discussed these allegations, and they discussed the emotive nature of the personal stories featured in these reports. For some participants, they provided more weight than the vaccine information leaflet provided by the government health service and dictated the vaccine decision. Many vaccine acceptors acknowledged their concerns regarding these alleged side effects, but were reassured by the continued, widespread use of the vaccine.
In addition to a lack of confidence, complacency was a key factor dictating hesitant parents' vaccination decisions. Parents were complacent about their daughter being at risk for HPV infection due to age, lifestyle choices, and/or a lack of family history of cervical cancer. They felt, as parents, that they could protect her from future infection by providing sex education, encouraging safe sex practices, and facilitating her attendance at screening programmes.
The ultimate vaccine decision appeared to lie in the participants' perception of risk. Vaccine acceptors acknowledged the risks associated with vaccination but prioritised disease and cancer prevention, whereas vaccine decliners prioritised the alleged risk of chronic side effects in their decision. All participants declared they were content with their respective vaccine decisions, and it was evident that the ultimate goal of these decisions was protection of their daughters' health.
The 10 TDF domains summarised above were then linked to several COM-B components: psychological capability; physical and social opportunity; and reflective and automatic motivation. The BCW was then used to identify intervention functions; 5 of the 9 intervention functions were found to be relevant: education; persuasion; environmental restructuring; modelling; and enablement. These 5 intervention functions were linked to 13 behaviour change techniques (BCTs), which are outlined in Table 3 of the paper. Potential intervention strategies were developed and are outlined in Table 4. ("All recommendations should be considered for future public health vaccination campaigns and intervention studies, as no single recommended BCT or intervention strategy will address all identified factors.")
In discussing the study's findings, the researchers note that, in addition to education, both persuasion and enablement will be key components of interventions to address vaccine confidence. These components could include, for example, sharing personal stories encouraging vaccination and describing the effects of the vaccine-preventable disease, as well as facilitating the spread of this pro-vaccine information. A positive example of this approach in Ireland was the 26-year-old HPV vaccine advocate Ms. Laura Brennan, who campaigned in the years preceding her untimely death from cervical cancer in March 2019.
In light of the fact that interviewees had revealed that the female parent was the primary healthcare decision-maker for the family, it may be suggested that future interventions to reduce HPV vaccine hesitancy should focus on this demographic. However, the over-identification of HPV as a female-specific disease has resulted in the feminisation of HPV and the HPV vaccine. Therefore, say the researchers, interventions should seek to normalise HPV vaccines as an important aspect for both men and women.
It is clear to the researchers that effective interactions with HCPs have the potential to alleviate concerns of vaccine-supportive parents and to motivate a vaccine-hesitant parent towards acceptance. They urge the development of communication strategies to support HCPs in recommending the HPV vaccine with confidence. Interviewees also discussed how they had appreciated, and been reassured by, their HCPs sharing their own personal vaccine decisions.
In conclusion: "The key strength of this study is the systematic approach (TDF, COM-B model and BCW) that was applied to map the parental HPV vaccine decision and to recommend a range of potential intervention strategies."
It is well established that changing behaviour is complex, and a systematic approach is required to understand the factors that influence vaccine uptake. In general, providing information alone does not change behaviour. Behavioural change has been shown to be more effective if interventions are based on principles drawn from evidence and theories of behaviour and behavioural change. This study took a systematic approach to understand the factors that influence human papillomavirus (HPV) vaccine uptake by parents of adolescent girls in Ireland to define suitable behaviour change interventions that would support positive vaccine decision-making in the future.
In Ireland, the quadrivalent HPV vaccine has been offered to all girls in the first year of second-level schools (aged 12-13 years) by the national healthcare service. Since September 2019, the vaccine has been available to boys in Ireland as well, but at the time of this research, only girls were included in the vaccination programme.) As reported here, although HPV vaccines has been deemed highly safe and effective, unsubstantiated reports of safety signals for the vaccines remain a public concern. In Ireland, HPV vaccination rates of 87% were reported in 2014/2015 but plummeted to 51% in 2016/2017.
This study applies the Theoretical Domains Framework (TDF), the capability, opportunity, motivation model of behaviour (COM-B) system of behavioural change, and the associated Behaviour Change Wheel (BCW) as tools for describing the factors that influence the parental HPV vaccine decision, identified using 13 semi-structured interviews with parents (31% of whom had declined the HPV vaccine for their daughter). (See the paper for a full discussion of the TDF, COM-B, and BCW.)
The interviews revealed that the vaccine decision was complex and often involved interactions between several TDF domains - namely, knowledge, memory, attention and decision processes, social role and identity, beliefs about capabilities, optimism, beliefs about consequences, goals, emotion, environmental context, and resources and social influences. Participants consulted with other individuals, to varying degrees, while making their vaccine decision; all parents discussed the essential role of healthcare providers (HCPs) in vaccine decision-making.
Even those who chose to decline the HPV vaccine discussed how they had accepted paediatric and other adolescent vaccines. Apprehension was reported to be primarily due to circulating claims of chronic side effects (e.g., fatigue, seizures) associated with the vaccine. Participants recalled radio interviews, television documentaries, newspaper articles, and online information that discussed these allegations, and they discussed the emotive nature of the personal stories featured in these reports. For some participants, they provided more weight than the vaccine information leaflet provided by the government health service and dictated the vaccine decision. Many vaccine acceptors acknowledged their concerns regarding these alleged side effects, but were reassured by the continued, widespread use of the vaccine.
In addition to a lack of confidence, complacency was a key factor dictating hesitant parents' vaccination decisions. Parents were complacent about their daughter being at risk for HPV infection due to age, lifestyle choices, and/or a lack of family history of cervical cancer. They felt, as parents, that they could protect her from future infection by providing sex education, encouraging safe sex practices, and facilitating her attendance at screening programmes.
The ultimate vaccine decision appeared to lie in the participants' perception of risk. Vaccine acceptors acknowledged the risks associated with vaccination but prioritised disease and cancer prevention, whereas vaccine decliners prioritised the alleged risk of chronic side effects in their decision. All participants declared they were content with their respective vaccine decisions, and it was evident that the ultimate goal of these decisions was protection of their daughters' health.
The 10 TDF domains summarised above were then linked to several COM-B components: psychological capability; physical and social opportunity; and reflective and automatic motivation. The BCW was then used to identify intervention functions; 5 of the 9 intervention functions were found to be relevant: education; persuasion; environmental restructuring; modelling; and enablement. These 5 intervention functions were linked to 13 behaviour change techniques (BCTs), which are outlined in Table 3 of the paper. Potential intervention strategies were developed and are outlined in Table 4. ("All recommendations should be considered for future public health vaccination campaigns and intervention studies, as no single recommended BCT or intervention strategy will address all identified factors.")
In discussing the study's findings, the researchers note that, in addition to education, both persuasion and enablement will be key components of interventions to address vaccine confidence. These components could include, for example, sharing personal stories encouraging vaccination and describing the effects of the vaccine-preventable disease, as well as facilitating the spread of this pro-vaccine information. A positive example of this approach in Ireland was the 26-year-old HPV vaccine advocate Ms. Laura Brennan, who campaigned in the years preceding her untimely death from cervical cancer in March 2019.
In light of the fact that interviewees had revealed that the female parent was the primary healthcare decision-maker for the family, it may be suggested that future interventions to reduce HPV vaccine hesitancy should focus on this demographic. However, the over-identification of HPV as a female-specific disease has resulted in the feminisation of HPV and the HPV vaccine. Therefore, say the researchers, interventions should seek to normalise HPV vaccines as an important aspect for both men and women.
It is clear to the researchers that effective interactions with HCPs have the potential to alleviate concerns of vaccine-supportive parents and to motivate a vaccine-hesitant parent towards acceptance. They urge the development of communication strategies to support HCPs in recommending the HPV vaccine with confidence. Interviewees also discussed how they had appreciated, and been reassured by, their HCPs sharing their own personal vaccine decisions.
In conclusion: "The key strength of this study is the systematic approach (TDF, COM-B model and BCW) that was applied to map the parental HPV vaccine decision and to recommend a range of potential intervention strategies."
Source
Vaccine Volume 41, Issue 7, 10 February 2023, Pages 1368-77. https://doi.org/10.1016/j.vaccine.2023.01.025
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