New approach for promoting HPV vaccination in college men based on multi-theory model (MTM) of health behavior change.

Dear Editor,

Human papilloma virus (HPV) is among the most common infections in college-aged men [1]. In men, it causes genital warts and several cancers that include penile, anal, and oropharyngeal carcinomas [2]. To prevent genital warts and HPV-related cancers, HPV vaccination has been recommended by the Advisory Committee on Immunization Practices for young adult males since 2011 [3]. College students are a salient target population for HPV vaccination surveillance and promotional activities because they are at an increased risk for HPV infection and also represent a priority group for HPV catch-up vaccinations [4]. Furthermore, about 48% young adults ages 18 to 24 have been enrolled in or have completed college between 2013 and 2015 [5]. However the rates of HPV vaccination in college males has been quite low and was recorded as 42.9% in 2013 with the odds of HPV vaccination being 2.97 (95% CI 2.48- 3.55) [4]. While the rates for HPV vaccination in the ages 18-21 years were 49.5% the rates in ages 22 -26 years were only 28.6% [4]. These rates were far lower than in women. Hence, there is a need to design and evaluate HPV vaccine promotion interventions for college men.

Very few interventional studies have been undertaken to assess the efficacy of educational interventions to promote HPV vaccination in college men. One such study was undertaken by the researcher in 2013 that utilized health belief model (HBM) [6, 7]. Using a randomized controlled trial, HBM-based intervention was compared with a traditional knowledge-based intervention in college- aged men ages 18-25 years. Repeated measures ANOVA demonstrated significant positive changes in the HBM-based group for knowledge and HBM constructs. Pretest/posttest regression analysis found that self-efficacy for taking the vaccine (p < 0.001), 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 0.351. However, the actual rates of HPV vaccination were not measured in this study. Also this study did not apply this approach for effectiveness testing.

HBM is an old theory and a newer theory has been proposed that is the multi-theory model (MTM) of health behavior change that is parsimonious, utilizes proven constructs from multiple theories, is culturally robust and can be used to design interventions at individual, group and community levels [8, 9]. This theory breaks the behavior change into initiation and sustenance. The theory proposes that participatory dialogue in which advantages outweigh disadvantages, behavioral confidence and changes in physical environment are crucial for health behavior change. For sustenance of behavior change the constructs of practice for change, emotional transformation and changes in social environment are important. The theory is new and in its initial applications to physical activity behavior in adults [10], portion size behavior in adults [11], and sleep behavior [12] has shown very good predictability. Hence, we propose that this theory be utilized for designing and evaluating the efficacy and effectiveness of brief MTM-based interventions to promote HPV vaccination in college men. The studies can utilize randomized controlled trials (RCTs) in which the independent variables will be the experimental MTM-based interventions which can be compared against knowledge-based interventions. The dependent variables can be the constructs of MTM, intent for vaccinations and actual vaccinations received. An instrument for quantitative study is attached in the Appendix 1.

The experimental MTM-based intervention can consist of two-sessions of 60 minutes each. The first session can entail administration of baseline instrument and activities to influence initiation of behavior of acquiring HPV vaccination. These can include a large group participatory dialogue on advantages and disadvantages of HPV vaccination in which the advantages would outweigh disadvantages. In order to build behavioral confidence, the steps for getting HPV vaccination and overcoming barriers in acquiring this vaccination can be underscored through a lecture and role play. In order to influence physical environment, the sites for getting this vaccination and support in getting HPV vaccination can be underscored through a lecture, group discussion, and provision of incentives. The second session after one week of the first session can aim at influencing sustenance of behavior of completing three doses of HPV vaccination. In order to influence the construct of practice for change the participants can be provided a check sheet and explained how to maintain it. Ways to overcome barriers in completing the schedule and adjusting one's routine can also be discussed during the session. In order to influence the construct of emotional transformation ways to direct one's emotions/feelings to the goal of getting all three doses of the HPV vaccination, ways for self-motivation and ways for overcoming self-doubt can be discussed. Finally, in order to influence changes in social environment, ways to enlist social support from friends, family and researcher can be discussed. Data can be collected post intervention for intent of getting vaccinated and after six months for actual vaccination rates.

The control knowledge-based intervention can also consist of two equivalent sessions of 60 minutes each. The first session can entail administration of baseline instrument and lectures on overview of sexually transmitted diseases, signs and symptoms of sexually transmitted diseases, HPV, consequences of HPV, significance of HPV, transmission of HPV, and prevention of HPV. The second session after one week of the first session can include lectures on history of vaccines, common vaccines, and HPV vaccine and will collect data through the 41-item instrument for the second time (at the conclusion of the intervention). We implore practitioners and researchers in HPV prevention to design and evaluate such efficacy and effectiveness trials

	Never	Hardly ever	Sometimes	Almost always	Always
Participatory dialogue: Advantages
If you get the HPV vaccination you will...
12. ... be protected against genital warts.	□	□	□	□	□
13. ... be protected against cervical cancer (females) or anal cancer (males).	□	□	□	□	□
14. ...improve your sexual health.	□	□	□	□	□
15. ...feel better about yourself.	□	□	□	□	□
16. ...feel less stress.	□	□	□	□	□
	Never	Hardly ever	Sometimes	Almost always	Always
Participatory Dialogue: Disadvantages
If you get HPV vaccination you will...
17. ... have side effects.	□	□	□	□	□
18. ... not have enough money to pay for it. (cost is around $150 for each dose)	□	□	□	□	□
19. ... be inconvenienced.	□	□	□	□	□
	Never	Hardly ever	Sometimes	Almost always	Always
Participatory Dialogue: Disadvantages
If you get HPV vaccination you will...
20. ... suffer from adverse effects.	□	□	□	□	□
21. ... have a false sense of protection against all sexually transmitted diseases (STDs).	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
Behavioral confidence
How sure are you that you will get the first dose of the HPV vaccine ...	□	□	□	□	□
22. ... in the near future?	□	□	□	□	□
23. ... in the near future without insurance (cost is around $150 for each dose)?	□	□	□	□	□
24. ... in the near future with your present schedule?	□	□	□	□	□
25. ... in the near future even if it is offered at a large distance from your home?	□	□	□	□	□
26. ... in the near future even if it causes side effects?	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
Changes in physical environment
How sure are you that you will...
27. ... be able to arrange payment for the first dose of the HPV vaccination?	□	□	□	□	□
28. ... be able to arrange a place to get the first dose of the HPV vaccination?	□	□	□	□	□
29. ... be able to arrange transportation to get the first dose of the HPV vaccination?	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
Emotional transformation
How sure are you that you can...
30. ... direct your emotions/feelings to the goal of getting all three doses of the HPV vaccination?	□	□	□	□	□
31. ... motivate yourself to get all three doses of HPV vaccination?	□	□	□	□	□
32. ... overcome self-doubt in accomplishing the goal of getting all three doses of HPV vaccination?	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
Practice for change
How sure are you that you can...
33. ... keep a record to monitor getting three doses of the HPV vaccination?	□	□	□	□	□
34. ... get three doses of HPV vaccination even if you encounter barriers?	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
35. ... change your schedule to get three doses of HPV vaccination if you face difficulties?	□	□	□	□	□
	Not at all sure	Slightly sure	Moderately sure	Very sure	Completely sure
Changes in social environment
How sure are you that you can get the help of a...
36. ... family member to support you with getting three doses of the HPV vaccination in the next 12 months?	□	□	□	□	□
37. ...friend to support you with getting three doses of HPV vaccination in the next 12 months?	□	□	□	□	□
38. ... health professional to support you with getting three doses of HPV vaccination in the next 12 months?	□	□	□	□	□
	Not at all likely	Somewhat likeky	Moderately likely	Very likely	Completely likely
Behavior change: Initiation
How likely is it that you will...
39. ... get the first dose of the HPV vaccination in the next month.	□	□	□	□	□
	Somewhat all likely	Moderately likeky	Very likely	likely	Completely likely
Behavior change: Sustenance
How likely is it that you will...
40. ... complete all three doses of HPV vaccination within the next 12 months.	□	□	□	□	□