HPV Vaccine Decision Narratives: Encouraging Informed HPV Vaccine Decision-making

Human papillomavirus (HPV) is the most common sexually transmitted infection among U.S. females and the most common among individuals in their late teens and early 20s. Although HPV infection is often asymptomatic and resolves without treatment within 2 years, some HPV types can cause cervical cancer and other diseases, with HPV types 16 and 18 causing the majority of cervical cancers. Each year in the United States, approximately 12,000 women are diagnosed with cervical cancer, and 4,000 women die from the disease. Since 2006, a quadrivalent HPV vaccine that targets HPV types 6, 11, 16, and 18 has been licensed for use in the United States for females 9-26 years, but HPV vaccine uptake by females in this age group remains low. College-age women represent a high-risk group for HPV infection. As such, interventions that aim to educate college-age women about the negative effects of HPV and the benefits of the vaccination are needed to promote adherence to HPV vaccination recommendations and to reduce the public health burden from HPV infection and associated cancers.

HPV Vaccine Decision Narratives: Encouraging Informed HPV Vaccine Decision-making is a 4-minute video intervention depicting decision narratives developed to educate college women about HPV vaccination. The video was developed using principles of culture-centric narrative theory, which states that health behavior can be influenced by messages delivered in a narrative form (e.g., testimonials, reenactments) and grounded in cultural values. In the development of the video, interviews were conducted with college women to learn how they made decisions to get vaccinated. Examinations of these interviews resulted in prototypical decision narratives for the video intended to engage other women and influence their vaccine decisions. Following exemplification theory, the idea that the communication deliverer plays a critical role in the effectiveness of narrative behavior change efforts, the video uses actresses playing like-age peers (female college students) to convey social trust and college health staff (medical experts) to motivate compliance. The decision narratives are as follows:

-- HPV susceptibility narrative: Tells stories of a sister or friend who has been diagnosed with HPV

-- Vaccine self-efficacy narrative: Shares ideas about overcoming barriers, such as the time needed to vaccinate, cost of vaccination, and availability of the vaccine on campus

-- Vaccine safety narrative: Gives advice about trusting your health care provider who recommends vaccination

-- Peer cues-to-act narrative: Shows a scene in which a peer encourages and recommends vaccination

-- Health care provider cues-to-act narrative: Shows a scene in which a health care provider encourages and recommends vaccination

The video encourages the uptake of the HPV vaccine while including factual information about vaccination (e.g., the vaccine is nearly 100% effective in protecting against four common HPV types, including two that cause cervical cancer) and the right time to get vaccinated (e.g., now is the right time for those who are sexually active or not).

The duration of the video is 4 minutes.

The intervention targets college women (aged 18-26).

The intervention is suitable for implementation in university health centers.

Required resources to implement the program include the following:

-- HPV Narrative Intervention Video version 1: Peer & Provider (with mother and daughter narrative)

--HPV Narrative Intervention Video version 2: Peer & Provider (without mother and daughter narrative)

Two versions of the video are available for dissemination. The narrative in the first version is told from the perspective of a mother who is also a physician and director of student health at a university. She talks about the HPV vaccine with her daughter and is glad when her daughter decides to get vaccinated. The second version does not use the mother and daughter narrative.

For costs associated with this program, please contact the developer, Suellen Hopfer. (See products page on the EBCCP website for developer contact information.)

A randomized controlled trial evaluated the effects of the intervention with female college students aged 18-26 who were not already vaccinated for HPV. Participants were recruited by email through the Pennsylvania State University Health Services Center. Participants included 404 students, most of whom were White (72%) and reported having health insurance coverage (90%). The majority of participants reported knowing about or having heard of HPV (92%). Half of the participants (50%) reported being sexually active (i.e., reported having engaged in penetrative intercourse in the past 30 days), and slightly more than half (53%) reported speaking with their mother about the HPV vaccine.

After consenting to participate in the study, participants were randomized to one of three treatment conditions or one of three control conditions. Participants in the treatment conditions viewed one of three videos depicting vaccine decision narratives: (1) a video of narratives delivered by peers, (2) a video of narratives delivered by medical experts, or (3) a video of narratives delivered by both peers and experts. Participants who were assigned to the control condition were not exposed to vaccine decision narratives; they either (1) viewed an informational video about HPV (a content-matched control), (2) accessed the campus website providing information about HPV and the vaccine (a topic-matched control), or (3) received no intervention. For purposes of the analyses, the control group data were collapsed after researchers determined the outcomes did not differ significantly among the three groups.

Participants were administered an online survey before the intervention to collect sociodemographic data and information on sexual activity and HPV knowledge. Immediately after watching the video, participants completed an online survey asking about their intent to vaccinate and their perceived vaccine self-efficacy. Differences in HPV vaccination between intervention and control group participants were assessed by an email asking them whether they received the first HPV vaccine shot 2 months after participating in an intervention or control condition. Secondary measures included HPV knowledge, sexual activity, daughter-mother HPV vaccine communication, HPV vaccination intent, and HPV vaccine self-efficacy, all measures assessed with the 40-item online survey derived from known scales. 

• The percentage of participants who had received the vaccination at 2-month follow-up was higher in the combined peer-expert intervention group than in the control group (21.8% vs. 11.8%; p=.036). No statistically significant differences were found when comparing the control group with either of the other intervention groups (peer-alone and expert-alone interventions) at 2-month follow-up.

Additional Findings

• The relationship between the intervention and HPV vaccination rate was mediated by intent for the combined peer-expert intervention (p<.001) but not for the peer-only intervention and expert-only intervention. In addition, the combined peer-expert intervention significantly increased vaccination (p<.001) via vaccine self-efficacy (p<.001) and intent (p<.001), while the peer-only intervention and the expert-only intervention did not.