ResultsThirty-four relevant studies were identified, of which 31 incorporated psychological health behaviour models or frameworks and three used socio-cultural models or theories. The primary studies used a variety of approaches to measure a diverse range of outcomes in relation to behaviours of professionals, parents, and young women. The majority appeared to use theory appropriately throughout. About half of the quantitative studies presented data in relation to goodness of fit tests and the proportion of the variability in the data. ConclusionDue to diverse approaches and inconsistent findings across studies, the current contribution of theory to understanding and promoting HPV vaccination uptake is difficult to assess. Ecological frameworks encourage the integration of individual and social approaches by encouraging exploration of the intrapersonal, interpersonal, organisational, community and policy levels when examining public health issues.
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Given the small number of studies using such approach, combined with the importance of these factors in predicting behaviour, more research in this area is warranted. IntroductionGlobally, inequalities in the incidence of cervical cancer exist by geographic area (, ), socioeconomic status (, ) and ethnicity (, ). Since licensure in 2006, many countries have introduced the Human Papillomavirus (HPV) vaccine into their national immunisation programmes for the primary prevention of cervical cancer. High coverage has the potential to reduce substantially cervical cancer incidence and mortality (, ).However, there is the potential to increase health inequalities if vaccine uptake is lower amongst less affluent and marginalised populations that may also have greater risk of developing cervical cancer. Evidence for differences in uptake has been shown. Globally, evidence from a systematic review and meta-analysis did not indicate strong evidence for associations by socioeconomic variables, but young women belonging to minority ethnic groups were less likely to receive the HPV vaccine. Further in the United States of America (USA), which delivers the HPV vaccination programme in the healthcare setting, young women without healthcare insurance coverage were less likely to be vaccinated.In relation to the United Kingdom (UK) routine school-based programme, studies have indicated a lack of association between initiation of the HPV vaccination course and area-level measures of deprivation (, ).
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However, lower uptake by minority ethnic young women has been reported (, ). In the catch-up programme, a higher level of deprivation is associated with a lower odd of initiation and completion of the HPV vaccination course (, ). Despite free access within the Danish healthcare-based programme, inequality by ethnicity and socioeconomic factors has been shown. Further, in the Norwegian school based programme, lower rates of initiation were reported for young women with mothers belonging to the lowest income group.The UK Medical Research Council Framework argues that complex interventions, such as an intervention to increase HPV vaccination uptake, should be developed and underpinned by appropriate theory which captures the likely process of behaviour change (, ). There is growing evidence that interventions developed with an explicit theoretical foundation are more effective and more likely to induce positive behaviour change (, ). Therefore, the aims of this literature review are: to provide an overview of theoretical models and frameworks that have been used in published research to explain behaviours in relation to HPV vaccination of young women, and: to consider the appropriateness of the theoretical models or frameworks for informing the development of interventions to increase uptake.
Materials and methodsMethods to identify relevant primary studies were based on those previously used by the study authors for systematic reviews in the field of HPV vaccination (, ). There are differences between ‘models’, ‘frameworks’, and ‘theories’.
Theories tend to be specific, with concepts which are amenable to hypothesis testing whereas models tend to be more prescriptive, specific and with a narrower scope. Conceptual frameworks are usually descriptive, showing relevant concepts and how they relate to each other.
Throughout the manuscript, we use the terminology ‘models’, ‘frameworks’ and ‘theories’ consistent with their use by the authors of included studies. Search strategyTo identify the relevant literature in relation to the HPV vaccine and theoretical models and frameworks, a search strategy previously used elsewhere (, ) was adapted which comprised the following combination of text words (searching the title and abstract) and Medical Subject Heading (MeSH) terms: ‘papillomavirus’ or ‘wart virus’, ‘vaccination’ or ‘immunisation’ or ‘immunization programmes’ or ‘wart virus vaccines’ and ‘theory’ or ‘theoretical model’.
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The following databases were searched from inception to 5th December 2013: CINAHL; Embase; Medline; PsycINFO; and ISI Web of Science & ISI Proceedings. All abstracts were saved using Endnote X3 reference manager software.After duplicates were removed, all titles and abstracts of identified studies were assessed by one author (HB-F) to consider their relevance for inclusion. Two reviewers independently reviewed potentially relevant full texts (HB-F, JC). Disagreements were resolved by discussion. Eligibility criteriaStudies were eligible for inclusion if a theoretical model or framework was explicitly used in the study design and the study reported findings to explain behaviours in relation to the HPV vaccination of young women aged nine to 18 years old.
Any study design, including qualitative and quantitative approaches, was eligible. No restrictions were imposed on the basis of publication date or language.
Potentially relevant conference abstracts or dissertations were checked to see if a full paper had been published in a journal. Reference lists and citation lists of primary studies and relevant systematic reviews were hand searched for additional references. Assessment of use of theoretical model or framework in primary studiesPresently, there is no standardised method or consensus for assessing use of theory within studies which can vary within different research disciplines. To assess the level of use of theory by the primary studies, the study was assessed as either: (i) partially applied: authors locate their study within a particular theory but then appear to abandon efforts to link, apply, or interpret their findings in relation to that context, or; (ii) consistently applied: the theory guides and directs the various phases of the research process and can be tracked throughout the primary study. This was quantified by assessing whether the authors justified their use of theory within the introduction or methods, presented their results in relation to the theory and whether they made reference to the theory within the discussion.This assessment was adapted from a five-point typology proposed by Bradbury-Jones et al.
On the levels of theoretical visibility which includes ‘implied’, ‘seemingly absent’, ‘partially applied’, ‘retrospectively applied’, and ‘consistently applied’. Primary studies were eligible for inclusion to the present study if a theoretical model or framework was explicitly used in the study design. Therefore, the categories ‘implied’ and ‘seemingly absent’ were not applicable to the present study and were not used. As discussed by Bradbury-Jones et al., studies which retrospectively apply theory are almost impossible to detect as the study authors often do not make this explicit.Although no formal standards for the evaluation of use of theory in studies exist, there are a number of measures and conventions to test the model fit and utility of the statistical model.
We report all goodness of fit tests which were presented by the primary study authors. The R-squared test and the Hosmer and Lemeshow test are widely used for linear and logistic regression models. For these tests, the variability of the response data explained by the statistical model is provided as a proportion between 0% and 100%. The greater the proportion explained, the better the fit of the statistical model. Internal consistency of the statistical model can be indicated using Cronbach's alpha: a proportion less than 60% suggests an unacceptable level of internal consistency.
In confirmatory factor analysis, the fit of the statistical model can be assessed using CMIN/DF (chi-square divided by the df value) with a value close to one indicating a good fit. A ratio greater than two represents an inadequate fit (, ). Characteristics of studiesThirty-one studies were identified which reported using at least one health behaviour theoretical model or framework (, ). The most widely reported were the theory of planned behaviour (, ) (n of studies = 15, 44.1%) and the health belief model (, ) (15, 44.1%).
The theory of reasoned action (, ) (n = 4, 11.8%), protection motivation theory (, ) (2, 5.9%), prospect theory (2, 5.9%), and theoretical domains framework (1, 2.9%) comprised the remainder. Three studies were identified which used sociocultural theories and frameworks: fundamental cause theory (1, 2.9%), vaccine perceptions, accountability and adherence model (1, 2.9%), and governmentality and disciplinary technologies of the self (1, 2.9%) (, ). Five studies (14.7%) (, ) empirically tested applicability of the theoretical model in relation to the actual HPV vaccination status of young women. AuthorsTheoretical modelAnalytical approachReporting of use of theoretical frameworkAppropriateness of modelOverall study findingsTheory of planned behaviourStructural equation modellingConsistently reportedInternal consistency: 31% to 99%; Comparative fit index: 96%Associations by subjective norms (p 0.01) and subjective norms (p 0.05)Theory of planned behaviourPrincipal components & linear regression modelConsistently reportedInternal consistency: 73% to 91%; Linear regression: accounts for 52% of varianceAssociations by attitudes (p. The most frequently reported study design was cross-sectional questionnaire (n of studies = 18, 52.9%). Other study designs included: qualitative (7, 20.6%); development of an intervention (1, 2.9%); systematic review (1, 2.9%); experimental (2, 5.9%); prospective questionnaire (1, 2.9%); development of a questionnaire (1, 2.9%); interventions to increase HPV vaccine uptake (2, 5.9%); and mixed methods (1, 2.9%).
Study participants included: parents (19, 55.9%); professionals involved in the HPV vaccination programme (8, 23.5%); young women (4, 11.8%), or; young women and their parents (4, 11.8%). Theory of reasoned action and theory of planned behaviourThe theory of reasoned action (, ) considers that behavioural intention is the best indicator of whether a specific behaviour is undertaken, and is influenced by a person's attitudes and subjective norms. The theory of planned behaviour (, ) extended this to include perceived behavioural control.Fifteen studies reported using the theory of planned behaviour (, ) and four studies used the theory of reasoned action (, ). Evidence was inconsistent as to which constructs influenced healthcare professionals' intentions to recommend vaccination (, ).
Communication of sexually related information was also examined. Constructs identified to affect mothers' intentions to have their daughter vaccinated differed between studies (, ). Association between cultural and socioeconomic factors were observed in one study in Israel , but not in a study undertaken in Canada.
Mothers' intentions to communicate sexually related information with their daughter were also examined. In another study, the provision of written information was shown to be insufficient to change parental perceptions of vaccination of their daughters. Young women's intentions and behaviours were examined in three studies (, ). Relevant constructs varied in two of the studies (, ). In the UK setting, no constructs were found to be associated with uptake, but associations with lower uptake by ethnic group were found. Health belief modelThe health belief model (, ) encompasses six main constructs to predict preventative behaviours: perceived susceptibility; perceived severity; perceived benefits; perceived barriers; self-efficacy; and call to action (, ). Fifteen studies (, ) were identified as to which reported using the health belief model.
In a systematic review of USA-based studies, the authors reported that parental acceptability of the HPV vaccine related to beliefs in effectiveness, susceptibility to HPV infection, and physician recommendation and barriers included cost and promotion of adolescent sexual behaviour. One study found that parents' perceived barriers and harms of the HPV vaccine, and perceived likelihood of their daughter developing cervical cancer, were related to vaccination status of their daughter.
Korean school health teachers' intentions to recommend vaccination , parental intentions to have their daughter vaccinated against HPV (, ), and information seeking behaviour were examined using the health belief model.Further, the model was used in developing interventions to increase parents' intention to vaccinate their daughters and increase uptake (, ). Communication of messages targeting mothers of vaccine eligible young women , a qualitative study examining Hispanic mothers' and daughters' perceptions of the HPV vaccine , and the Parental HPV Survey were also captured.
Three studies reported using the health belief model to explain young women's behaviour in relation to the HPV vaccine (, ), but the influential domains were inconsistent. Protection motivation theoryProtection motivation theory (, ) predicts that the intention to protect depends upon four factors: perceived susceptibility; perceived severity; response efficacy: and perceived self-efficacy (, ). Two studies used the protection motivation theory (, ). Response efficacy, self-efficacy, and subjective norms in the Canadian school-based vaccination programme were identified to influence mothers' intentions to vaccinate their daughters. Message framing did not influence Canadian parents' intentions to have their daughter vaccinated. Prospect theoryProspect theory proposes that gains and losses are valued differently, which in turn can alter decision-making. ‘Gain frames’ highlight the benefits of complying with a recommended behaviour or avoidance of negative consequences.
‘Loss frames’ portray the negative consequences of noncompliance. In one study, no differences in effectiveness of ‘gain framed’ versus ‘loss framed’ messages to increase Irish parents' HPV vaccination intentions were observed. However, in another study in a USA setting, mothers were reported to respond more favourably to positive messages.
Theoretical domains frameworkThe theoretical domains framework integrated multiple behaviour change theories to include 12 domains: (i) knowledge; (ii) skills; (iii) social/professional role and identity; (iv) beliefs about capabilities; (v) beliefs about consequences; (vi) motivation and goals; (vii) memory, attention, and decision processes; (viii) environmental context and resources; (ix) social influences; (x) emotion regulation; (xi) behavioural regulation; and (xii) nature of the behaviour. In one study, all domains were identified to be related to Irish healthcare professionals behaviour, with the exception of the ‘memory, attention, and decision process’ construct. Fundamental cause theoryFundamental cause theory argues that health disparities persist because those with higher socioeconomic position have greater access to resources which can improve health.
One study used fundamental cause theory to examine the potential impact of the USA HPV vaccination programme on future cervical cancer inequalities, and found unequal parental knowledge and receipt of a health professional recommendation contributed to disparities in uptake by ethnicity and socioeconomic status. Assessment of use of theoretical model or theory in primary studiesOverall, the majority (27 of 34) of studies presented the use of the theory or theoretical model consistently throughout the research process. It appeared that the theory guided and directed the various phases of the research process which could be tracked throughout the article. There were seven studies that appeared (from the information presented in the paper) to inconsistently use theory (, ). One did not justify the selected theory within the manuscript. In two qualitative studies, the authors reported that the interview guide was developed using a theory but did not present study findings with reference to the theory (, ).
Similarly, in a study reporting an intervention developed using the health belief model, the authors did not analyse the data using the health belief model. Two studies did not explicitly refer to their theoretical framework in the discussion of their research findings (, ), although one of these mentioned the limitations of a theoretical approach within the discussion. Restrictions imposed on authors, such as journal word limits and preferences, may have limited their ability to explicitly state their use of theory.Internal consistency by grouping constructs was reported by 19 studies (, ), of which ten studies (, ) indicated lower internal consistency by some constructs (range: 20% to 65%). Lower explanatory power (. DiscussionThe study aimed to provide an overview of the theoretical models or frameworks used to explain behaviours in relation to HPV vaccination of young women.
Overall, 34 primary studies were identified which investigated a wide range of issues including: intentions to vaccinate or recommend vaccination against HPV; communication of information related to sexual transmission of HPV; interventions to increase acceptability; development of a questionnaire; power relationships; and explanation of health inequalities. The primary studies targeted a wide range of population groups, with parents predominating, in addition to healthcare professionals and young women themselves. Theory appeared to be consistently used by the primary studies throughout the research process to examine issues. The majority of quantitative studies that used behaviour change theory constructs gave an indication of the goodness of fit. However, some of the studies failed to report goodness of fit tests, or the statistical models presented and explained only a small proportion of the variability in the data.Theoretical models related to individuals' health-related behaviour were predominantly used by the primary studies, of which the Theory of Reasoned Action, Theory of Planned Behaviour and the Health Belief Model were the most frequently reported. Behavioural theories and models are considered an important tool in effective behaviour change interventions and programmes (, ).
Across a wide range of settings, relationships between internal constructs from the Theories of Planned Behaviour and Reasoned Action which measure individual motivational factors based on behavioural, normative and control beliefs were identified. Relationships between individuals' beliefs in relation to threat perception and behavioural evaluation, informed by the Health Belief Model, were also widely reported. These potentially modifiable beliefs can shape individual behaviour and can be targeted in order to bring about health-related behaviour changes.The importance of the individual constructs as determinants of intentions and HPV vaccine-related behaviour varied by the population under consideration. For example, constructs of the Theory of Planned behaviour identified to be associated with Irish, American and Canadian mothers' intentions to vaccinate their daughters were inconsistent (, ).
This highlights that, to be effective, individual-level behavioural interventions to increase HPV vaccination uptake may need to be adapted to the specific needs of the population under study. Similar to the findings presented in this study, a recent systematic review which use of theories of behaviour changes to prevent communicable diseases identified individual-level theories and models were most frequently used. However, less than half of the interventions which used theories based on individual-level behaviour were found to be effective.The strength of an individualistic approach is the ability to highlight the complexity of factors which contribute to the behaviour of groups of individuals. However, we consider that there are a number of important shortfalls of the approaches undertaken by the studies in relation to developing interventions to increase uptake of HPV vaccination programmes.Firstly, only five studies (, ) empirically tested the assumptions and applicability of the theoretical model in relation to the actual, or self-reported, vaccination status of young women.
Consequently, there is little available evidence of the extent that individual determinants of behaviour contribute to uptake, or inequalities in uptake, of the HPV vaccination programme, and knowledge about how to change behaviour is currently limited. This may reflect greater challenges in obtaining young people's consent for research.The studies infrequently reported wider determinants of health, such as social, economic, and environmental factors.
These can either directly or indirectly affect an individual's ability or power to perform a specific behaviour. Although a number of psychological theoretical models or frameworks, for instance the health belief model, include factors relating to wider determinants (such as perceived costs) the focus is on individual perceptions and beliefs rather than structural constraints.
Only two studies acknowledged this limitation in the discussion (, ). Incorporating wider determinants of health in relation to HPV vaccine uptakeThe limitations of using theories of individual behaviour to explain HPV vaccination uptake can be counteracted using a theoretical model or framework which encompasses intra- and inter-personal behaviour and also acknowledges the wider determinants of behaviour. Ecological frameworks, such as the socio-ecological (, ), structural–ecological , and the social-ecology models are of particular relevance. Ecological frameworks may provide more comprehensive frameworks for understanding the multiple and interacting determinants of health behaviours which may operate at several or all of following levels: public policy; community; organisational; interpersonal; and intrapersonal. Importantly, an ecological framework assists with the identification of appropriate levels at which to target interventions informed by relevant theories.A qualitative systematic review and evidence synthesis illustrated how a young woman's access to the HPV vaccine is shaped by decisions at different levels of the socio-ecological model including: the policy context in relation to costs and accessibility; social norms and values of sexual activity and vaccine beliefs; the views and actions of healthcare professionals; and parental consent procedures. This supports how an intervention aimed at individual-level changes to behaviour is unlikely to be successful if other barriers are not simultaneously addressed. ConclusionCurrently, it is difficult to draw firm conclusions about the contribution of theory promoting HPV vaccination uptake and addressing inequalities due to a wide variety of approaches and inconsistent findings from any single theory.
The use of theoretical models and frameworks is heavily weighted towards intra- and inter-personal factors that affect individuals' intentions. We suggest that a more comprehensive approach, which also accounts for the broader social, cultural and political context, is required. Given the small number of studies that examined ecological frameworks, combined with the importance of these factors in predicting behaviour, more research is required to examine whether such frameworks can assist in developing interventions which increase uptake of HPV vaccination programmes. The study was undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence. Joint funding (MR//1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.
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The study was also supported by the NIHR Health Protection Research Unit in Evaluation of Interventions (ISHPU1112100). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England. Thanks are also due to Dr Joanna Crichton (University of Bristol) who undertook checking of full texts for the study inclusion.
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