Multi-Theory Model and Predictors of Likelihood of Accepting the Series of HPV Vaccination: A Cross-Sectional Study among Ghanaian Adolescents

"Identifying adolescents predisposing, enabling, reinforcing, and societal (cultural) factors that facilitate and hinder HPV vaccination is important for the development of effective interventions to increase the HPV vaccination behavior among adolescents in Ghana."

While some research has identified religious, political, socioeconomic, and ethical challenges to human papillomavirus (HPV) vaccination in Ghana, studies that utilise theoretical frameworks to identify factors contributing to low HPV vaccination uptake are limited. Thus, the present study advances a multi-theory model (MTM) of behaviour change as a framework that can be used to predict both the initiation and completion of HPV vaccination behaviours in adolescents in Ghana.

The MTM has 2 main components, each of which involves 3 constructs:

1. Initiation of the behaviour change:
   • A participatory dialogue, which involves consideration of the difference between advantages and disadvantages of engaging in a behaviour (e.g., the initiation of HPV vaccination).
   • Behavioural confidence, which is a function of individual certainty to perform a given health behaviour change (e.g., confidence in getting HPV vaccination) in the future.
   • Changes in the physical environment, which can be used to evaluate whether the availability and accessibility of physical factors (e.g., cost and availability of HPV vaccination) could facilitate a behaviour change.
2. Continuation of a given behaviour:
   • Emotional transformation, which is changing an individual's emotions toward a given behaviour change (e.g., making sure to complete the recommended doses of HPV vaccination).
   • Practice for change, which highlights the individual's considering a given behaviour change, engaging in iterative processes to overcome barriers, and remaining focused on sustaining a behaviour change (e.g., keeping journals to remind oneself about going for a second dose of HPV vaccination).
   • Changes in the social environment, which stipulates that creating social support from the environment (e.g., parental and primary care provider support for HPV vaccination) helps in sustaining a given health behaviour.

Adolescents (n = 285) between the ages of 12 and 17 years old were recruited from 4 schools in the Ashanti Region in Ghana to complete a 44-item survey based on MTM constructs. The outcome variables for the study were the likelihood of adolescents getting the first dose of HPV vaccination within the next month and the likelihood of adolescents completing the recommended series of HPV vaccination within the next 12 months.

Selected findings:

• Many of the participants had neither heard about HPV (92.3%) nor HPV vaccinations (95.4%). (Since 2013, there have been 2 short-lived HPV vaccination demonstration projects completed in Ghana.)
• Female participants were more likely than males to report a willingness to get the first dose of the vaccine and to complete the series, as were participants between ages 12 and 15 years (vs. those between ages 16 and 18 years)
• In hierarchical multiple regression analyses for initiation, the results indicated that 23.6% of the variance in adolescents' likelihood of getting the first dose of HPV vaccination was explained by the MTM. Significant predictors of adolescents' likelihood of getting the first dose of HPV vaccination were perceived beliefs and change in a physical environment (p < 0.001), with each variable accounting for 6.1% and 8.8% of the variance, respectively.
• 36.0% of the variance in the likelihood of completing the recommended doses of HPV vaccination was explained by the MTM, with significant predictors of adolescents' likelihood of completing HPV vaccination recommended series including perceived beliefs, practice for change, and emotional transformation (p < 0.001), with each variable accounting for 7.8%, 8.1%, and 1.1% of the variance, respectively.
• Perceived beliefs that HPV causes cancer, that HPV vaccination is effective in preventing cancer, and that HPV vaccination is effective in adolescents' early years were significantly associated with the initiation and completing of HPV vaccination.

Recommendations for healthcare providers and interventions aimed at promoting the initiation and completion of HPV vaccination among adolescents in Ghana:

• The finding of low awareness of HPV and the vaccine suggest the need to design and implement intervention studies to educate Ghanaian adolescents. In other studies, effective interventions have focused on education regarding the etiology and provided epidemiological evidence of HPV, its related diseases, available vaccines, and their effectiveness to prevent those diseases.
• While it is important to educate females about HPV vaccination, researchers have found that adolescent boys' willingness to accept vaccination may be enhanced by knowledge of penile, anal, mouth, and throat cancers and the effectiveness of the vaccination in preventing those types of cancers.
• Though physical environments, which may influence adolescents' vaccine intentions, are modifiable, for most people in low-and middle-income countries, access to transportation to vaccination facilities and paying for vaccination bills are challenges that would require government support or policy changes.
• Clinicians could encourage adolescents to practice the habit of keeping records or journals to remind themselves of the next vaccination scheduled visit, practice strategies to overcome HPV vaccination barriers, and adjust their regular schedules to accommodate the vaccination schedule.
• Future interventions could address adolescents' emotional transformation by helping them channel their feelings and emotions, teaching self-motivation, and introducing strategies to overcome self-doubt to enhance their probability of completing the HPV vaccination series.