An Integrative Theoretical Framework for HPV Vaccine Promotion Among Male Sexual Minorities

"Tailoring health education interventions for this population requires the identification of modifiable beliefs salient to MSM when making decisions about HPV vaccination."

In order to address the low uptake of human papillomavirus (HPV) vaccination among male sexual minorities (MSM) in the United States (US), it is thought that efforts to change healthcare provider behaviours regarding the recommendation of HPV vaccination are needed, along with tailored, community-based interventions for MSM to increase awareness, foster positive attitudes and beliefs regarding HPV vaccination, and heighten individual intention to get vaccinated within a given time frame. The objective of the current study was to quantify the behavioural intentions of young adult MSM to initiate HPV vaccination and test a theoretical model of HPV vaccine decision making that goes beyond the most proximate determinants of intention, acceptability, or willingness.

The integrative model of behavioural prediction (IM) was used to inform this study. This theoretical approach postulates that a set of population-specific salient beliefs underlies the formation of attitudes toward HPV vaccination, perceived norms in favour or against vaccination, and perceived control over one's ability to get vaccinated if so desired. The effects of attitudes, norms, and perceived control on HPV vaccination are, in turn, mediated by an individual's behavioural intention. The model also specifies that beliefs related to HPV vaccination are influenced by a variety of background factors inclusive of personal characteristics and experiences, sociocultural factors, and exposure to information.

Structural equation modeling (SEM) was used to test this model. SEM allows for the estimation of the associations among latent and measured variables and attempts to remove measurement error from these estimates. This allows the complete propositional structure of a theory to be tested, including direct and indirect effects.

Participants in the study were 575 English-speaking men 18 to 26 years of age and living in the US who had not initiated the HPV vaccine series and who identified as gay, bisexual, and/or had ever had sexual contact with another male.

In brief, salient HPV-related beliefs included:

• Behavioural beliefs: Protecting sex partners from HPV was the belief with the highest expectancy value. On average, participants indicated little concern regarding vaccine-related side effects.
• Normative beliefs: Gay male friends appear to have some influence over HPV vaccine perceptions; the least influential referents were fathers. All normative referents contributed positively toward perceived norms, yet their influence with regard to this decision was low. ("Lower normative influence among MSM may result from a desire to keep issues related to their sexuality private...").
• Control beliefs: Health insurance is the strongest perceived facilitator of vaccination, followed by the ability to get vaccinated at locations that offer HIV testing. Participants expressed a moderate degree of self-efficacy in getting vaccinated if they had to discuss their sexual orientation with a healthcare provider. Self-efficacy was also positively associated with perceived behavioural control.

Overall, participants expressed positive attitudes toward vaccination, supportive norms, and perceived control over their decision to get vaccinated. More than half (57%) of participants indicated they were "likely/very likely" to initiate HPV vaccination.

The study found that the strongest determinant of behavioural intention was attitude. According to this model, HPV-related attitudes can be changed by increasing beliefs in physical and psychological benefits of vaccination and decreasing concerns about side effects. Some of the beliefs most strongly associated with attitude toward HPV vaccination were experiential (e.g., feeling protected from HPV and allaying the worry associated with sexual activity). The vaccine therefore becomes a method of reducing anxiety by increasing a sense of protection.

Perceived threat and information orientation serve as the key motivational factors related to perceived advantages of vaccination. As such, this theoretical model predicts that messages regarding the advantages of HPV vaccination are more likely to be systematically processed if a threat stimulus is present. The researchers suggest that threat messages should focus on the social, emotional, and physical consequences of HPV infection and use a combination of communication channels to reach individuals with varying health information orientations.

Considering the finding that men who believed that their health insurance covered the vaccine had higher perceived control and higher intentions to get vaccinated, the researchers suggest that health plans should cover HPV vaccination for MSM up to age 26 without cost-sharing. This information should be included in promotion messages, they say. In addition, bundling services like HPV vaccination with other recommended vaccinations, sexually transmitted infection (STI) screening, and HIV prevention (e.g., preexposure prophylaxis) for MSM may increase the uptake of these services.

Self-efficacy was inversely related to a general tendency to conceal aspects of one's sexual orientation and a suspicion of healthcare providers. According to the researchers, the likelihood of sexual orientation disclosure will increase if providers can demonstrate they care about and are knowledgeable about the unique health issues and concerns of lesbian, gay, bisexual, and transgender (LGBT) populations. "This would improve patient-provider interactions and allow for more opportunities to recommend preventive services like HPV vaccination."

The exogenous variables in the model identified three subpopulations of MSM who may benefit from targeted health education interventions:

1. "HIV-infected individuals exhibited higher perceived threat of HPV....Messages focusing on anal cancer prevention may be particularly effective for HIV-infected MSM."
2. "[B]isexual identity was indirectly associated with intentions through lower self-efficacy resulting from higher concealment of sexual orientation and suspicion of health care providers....Lack of trust in patient-provider interactions among bisexual men may in turn result in fewer opportunities for vaccination."
3. "Men in monogamous relationships exhibited lower levels of perceived threat....Further research is needed to identify the specific targets of behavioral interventions for this unique subpopulation."

In conclusion, the researchers identified that attitudes did not fully account for the association between perceived benefits and intention, and that there are normative processes involved in the formation of personalised risk and health information seeking. In the final model explicated in this study, "a number of modifiable determinants of HPV vaccine intentions - both psychosocial and environmental - were identified. These determinants can be used to target and tailor behavioral interventions for this priority population and inform the content of patient-provider conversations about this vaccine."