Identifying Knowledge-Attitude-Practice Gaps to Enhance HPV Vaccine Diffusion

Abstract

To examine differences in knowledge, attitudes, and related practices among adopters and nonadopters of the human papillomavirus (HPV) vaccine, the researchers conducted 83 in-depth interviews with 18- to 26-year-old women. The study identified knowledge-attitude-practice gaps in the context of the HPV vaccine to explain why diffusion of a preventive innovation (such as the HPV vaccine) requires targeted risk communication strategies in order to increase demand. Salient findings included similarities between vaccinated and unvaccinated women's lack of knowledge and uncertainties about HPV and cervical cancer. Vaccinated women who had no knowledge of HPV or no-risk/low-risk perceptions of HPV reported receiving vaccination, indicating HPV risk protection behavior could precede knowledge acquisition for vaccinated women. These vaccinated women identified an interpersonal network supportive of vaccination and reported supportive social influences. Among unvaccinated women, unsupportive vaccination attitudes included low perceived personal risk of HPV. In contrast, unvaccinated women often cited erroneous beliefs that HPV could be avoided by abstinence, monogamy, and knowledge of their partners' sexual history as reasons that the vaccine was not personally relevant. Unvaccinated women cited interpersonal influences that activated short- and long-term vaccination safety and efficacy concerns. Different levels of fear regarding the HPV vaccine may underlie (a) attitudinal differences between vaccinated and unvaccinated women in perceived vaccination value and (b) attitude-practice gaps.

Acknowledgments

The study described in this chapter was supported by Cooperative Agreement Number 1U48DP001932-01 from the Centers for Disease Control and Prevention. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors acknowledge the assistance of two graduate research assistants who helped in the early development of this article.

Notes

¹The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practice recommends that young women ages 11 to 26 years receive the HPV vaccine.

²The representation of students recruited from both of these methods reflected the demographic makeup of young women at the Midwestern state university; the majority of the students were White (n = 77), with a minority of women from African American (n = 4), and other racial or ethnic groups (n = 2). Participants who received fewer than three HPV vaccine doses were excluded from analysis. Although these women represent an important population to be studied with respect to HPV vaccination adherence, vaccine adherence behavior is ancillary to the study's core research question. We considered these types of women in a different study (Head & Cohen, 2012). Second, given the small number of women (n = 3), it was not possible to reach saturation to represent the unique perspectives of this group, although their reasons for not following through seemed to align with the reasons given by other nonadopters, and their reasons included some concerns about the vaccine's efficacy, injection pain, convenience, and costs.

³Women were recruited from the general campus population through flyers posted on research recruitment boards of the university campus (in prominent locations such as the student union building) and by word of mouth. Women were recruited also from a department research study participant pool (consisting of more than 8,000 enrolled students study during this study period); e-mail and in-person notifications were sent to students advising them of this research opportunity.

⁴Detailed study interview protocols are available from the lead author. Participants were interviewed and vaccinated before the U.S. debut of Cervarix (GlaxoSmithKline), a bivalent vaccine that protects against HPV types 16 and 18. All vaccine references are to Gardasil (Merck).

⁵First, the principal investigator and research assistants read transcripts and met to discuss core concepts critical to developing an organizational model for the themes related to HPV and HPV vaccination knowledge, attitudes, and practices. Then, two research assistants (including the second author) independently openly annotated the transcripts by theme. The authors independently reviewed transcripts and assessed participant responses for HPV vaccination status before convening to compile and compare findings. The authors then deployed a constant-comparative methodology in which “codes and categories are mutable until late in the project, because the research is still in the field and data from new experiences continue to alter the scope and terms” (Lindlof & Taylor, 2002, p. 218) of the analytic framework.

⁶It is important to note that this was not due to a knowledge-driven view that regular Pap screening and follow up could prevent advanced cervical cancer as reasoning that they did not need the vaccine.