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p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3

Available online at w

Public Health

journal homepage: www.elsevier .com/puhe

Original Research

Health Belief Model applied to non-compliance with HPV vaccine among female university students

E.M. Donadiki a,*, R. Jiménez-Garcı́a b, V. Hernández-Barrera b, P. Sourtzi a, P. Carrasco-Garrido b, A. López de Andrés b, I. Jimenez-Trujillo b, E.G. Velonakis a

aDepartment of Public Health, Faculty of Nursing, University of Athens, Athens, Greece bDepartment of Preventive Medicine and Public Health and Medical Immunology and Microbiology, Av. of Athens,

Alcorcón, Madrid, Spain

a r t i c l e i n f o

Article history:

Received 12 February 2013

Received in revised form

14 October 2013

Accepted 6 December 2013

Available online 13 February 2014

Keywords:

Health Belief Model

Human papillomavirus

Vaccine

* Corresponding author. Department I, Av. o E-mail addresses: elizadonadiki5@hotma

0033-3506/$ e see front matter ª 2013 The R http://dx.doi.org/10.1016/j.puhe.2013.12.004

a b s t r a c t

Objectives: To investigate the reasons for refusal of human papillomavirus (HPV) vaccina-

tion, and to explore participants’ perceptions and attitudes about Health Belief Model

(HBM) constructs (perceived susceptibility, perceived severity, perceived benefits,

perceived barriers, cues to action and self-efficacy) among a sample of female university

students.

Study design: Cross-sectional. A self-administered questionnaire based on the HBM was

used.

Methods: Confirmatory factor analysis was applied to the data to examine the construct

validity of the six factor models extracted from the HBM. The predictors of non-HPV

vaccination were determined by logistic regression models, using non-HPV vaccination

as the dependent variable.

Results: The sample included 2007 students. The participation rate was 88.9% and the

percentage of non-vaccination was 71.65%. Participants who had high scores for ‘general

perceived barriers’, ‘perceived barriers to vaccination’, ‘no perceived general benefits’, ‘no

perceived specific benefits’ and ‘no general benefits’ were more likely to report being

unvaccinated.

Conclusions: The findings demonstrated the utility of HBM constructs in understanding

vaccination intention and uptake. There is an urgent need to improve health promotion

and information campaigns to enhance the benefits and reduce the barriers to HPV

vaccination.

ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

f Athens s/n, Alcorcon, Madrid 28922, Spain. Tel.: þ34 914888804; fax: þ34 914888955. il.com, edonadik@nurs.uoa.gr, elizabethmadrid13@gmail.com (E.M. Donadiki). oyal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3 269

Introduction

Worldwide, cervical cancer is one of the most prevalent

gynaecological malignancies. Human papillomavirus (HPV) is

a commonsexually transmitted infection, andHPV infection is

necessary for the development of cervical cancer.1,2 Vaccina-

tions are one of the most successful public health approaches

to prevent and control infectious diseases. HPV vaccination

offers a unique opportunity for the primary prevention of

cervical cancer. However, to be a successful public health tool,

it needs to be widely implemented among the appropriate

target population, preferably prior to first sexual intercourse.3

Greecewas one of the first countries in the EuropeanUnion

to introduce HPV vaccines into its national vaccination pro-

gramme in January 2008. The vaccines are delivered free of

charge to females aged between 12 and 26 years.4 Despite the

fact that the vaccination is free of charge, uptake rates range

between 11% and 25.8% in Greece.5e7

Previous studies have indicated that common reasons for

not receiving the HPV vaccine are the perception of low risk or

not needing the vaccine, lack of vaccine awareness, doubt

about the safety and efficacy of the vaccine, fear of side-

effects, inadequate testing of novel vaccines that may be

harmful and weaken the immune system, lack of provider

recommendation and cost.5,8e16 This study used the Health

Belief Model (HBM) as the theoretical framework. This psy-

chological model attempts to explain and predict health be-

haviours, and is used in assessing health-behaviour

interventions by focussing on the attitudes and beliefs of in-

dividuals. It includes concepts such as perceived susceptibil-

ity, perceived severity, perceived benefits, perceived barriers,

cues to action and self-efficacy. The HBM has been used

extensively to study vaccination beliefs and behaviours, and

has also been used in vaccination research to identify pa-

tients’ perceptions of disease and vaccination.2,9,17,18

The aims of this studywere to investigate themain reasons

for refusal of HPV vaccination, and to explore participants’

perceptions and attitudes about HBM constructs (perceived

Table 1e Items of attitudes based on the Health Belief Model dim for a sample of female university students in Athens.

Item number

Items

I-1 I do not believe in vaccinations generally.

I-2 Vaccinations are not effective and do not prevent diseases.

I-3 It is not important to receive all vaccines.

I-4 It is preferable to get the disease and to be protected

naturally than to vaccinate.

I-5 I do not have confidence that the HPV vaccine is safe.

I-6 I believe that if I receive the HPV vaccine, I will not be

protected from cervical cancer.

I-7 I believe that if I receive the HPV vaccine, I will not be

protected against HPV.

I-8 I do not have enough information about HPV.

I-9 I do not have enough information about the HPV vaccine.

I-10 Cost would influence my uptake of the HPV vaccine.

I-11 My social security did not allow me to receive the vaccine.

I-12 I did not have money for vaccination.

I-13 My sexual behaviour is safe.

I-14 I do not believe that HPV is exceptionally harmful.

susceptibility, perceived severity, perceived benefits,

perceived barriers, cues to action and self-efficacy) among a

sample of female university students in Athens.

Methods

This cross-sectional, descriptive study assessed attitudes

about HPV vaccination among female university students in

Athens, Greece using a self-administered questionnaire based

on the HBM. Female students at each university were enrolled

using class lists, in order to evaluate students studying all

degrees and classes. Details on the survey methodology are

available elsewhere.7

The inclusion criteria of the study were: age 18e26 years,

university student and able to speak Greek. Data were

collected between September 2010 and October 2011.

HPV vaccine uptake was measured by asking the study

population if they had been completely vaccinated (three

doses) against HPV.

The questionnaire collected demographic variables and

some health-related variables considered as independent

variables. The independent variables were analysed and the

categories were defined as follows.

� Sociodemographic characteristics: age group (18e20 and 21e26 years), employment status (yes/no) and current

relationship status (non-stable relationship vs stable rela-

tionship); and

� Health and sexual behaviour variables: smoking habits (non-smoker vs smoker), ever visited a gynaecologist (yes/

no), use of condoms (never/sometimes or always), use of

contraceptives (yes/no) and previous sexual experience

(yes/no).

Beliefs regarding HPV, cervical cancer and vaccination

were measured using the HPV Beliefs Scale. This instrument

comprises 14 items representing the six dimensions of the

ensions included in the questionnaire. Descriptive results

Absolutely disagree

Disagree Neither disagree nor agree

Agree Absolutely agree

10.4% 32.0% 36.5% 17.7% 3.5%

9.8% 61.9% 25.7% 2.4% 0.3%

16.6% 46.3% 27.4% 8.0% 1.6%

16.7% 42.4% 28.5% 9.8% 2.6%

3.9% 50.8% 24.8% 17.2% 3.4%

3.8% 45.6% 31.7% 15.9% 3.1%

3.3% 44.4% 35.8% 13.4% 3.1%

7.2% 26.5% 21.0% 37.6% 7.6%

6.3% 24.2% 22.4% 38.6% 8.5%

25.7% 41.4% 16.3% 11.6% 5.0%

24.4% 37.9% 25.9% 9.5% 2.4%

38.2% 43.4% 13.2% 3.9% 1.2%

2.4% 5.0% 22.7% 45.7% 24.1%

35.0% 44.4% 17.1% 2.3% 1.3%

Table 2 e Distribution according to sociodemographic and health-related variables and proportion of individuals unvaccinated against human papillomavirus (HPV) among a sample of female university students in Athens.

Variables Distribution Non-HPV vaccination

n % % 95% CI

Age group (years) 18e20 1244 61.9 70.5 67.9e73.0

21e26 763 38.0 73.5 70.3e76.5

Employment

statusa No 1546 77.0 70.5 68.2e72.7

Yes 461 22.9 75.4 71.3e79.2

Relationship

statusa Non-stable 890 44.3 68.9 65.9e72.0

Stable 1117 55.6 73.7 71.1e76.3

Smoking statusa Non-smoker 1532 76.3 70.3 68.0e72.6

Smoker 475 23.6 75.7 71.7e79.4

Have you ever

visited a

gynaecologist?a

No 663 33.0 78.8 75.6e81.8

Yes 1344 66.9 68.0 65.5e70.5

Use of condoms Never/

sometimes

627 39.1 74.1 70.6e77.4

Always 973 60.8 70.7 67.8e73.5

Use of

contraceptives

No 1520 82.3 71.7 69.5e74.0

Yes 326 17.7 69.3 64.1e74.1

Previous sexual

experience

No 603 30.0 69.9 66.2e73.5

Yes 1404 69.9 72.3 70.0e74.6

Total 2007 71.6 69.6e73.6

CI, confidence interval. a P < 0.05 for coverage (Chi-squared test).

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3270

HBM: ‘no perceived severity’ (one item), ‘no perceived sus-

ceptibility’ (one item), ‘perceived general barriers’ (two items),

‘perceived barriers to vaccination’ (three items), ‘no perceived

general benefits’ (four items) and ‘no perceived specific ben-

efits’ (three items). University students responded using a five-

point Likert scale (1 ¼ absolutely disagree, 2 ¼ disagree, 3¼ neither disagree nor agree, 4¼ agree, 5¼ absolutely agree). The items and descriptive results are shown in Table 1. In

order to make the results easier to understand, all questions

were scored toward beliefs that would result in non-

adherence to vaccination. Therefore, higher scores reflect

stronger beliefs about the dimension that would result in non-

compliance.

Statistical analysis

The distribution of the study population was described ac-

cording to study variables and the proportion of non-

vaccinated individuals according to these same variables.

Next, confirmatory factor analysis was applied to the data

to examine the construct validity of the six dimensionmodels

extracted from the HBM. Initially, 14 predictors (items) were

used to test the model. The Kaiser-Meyer-Olkin (KMO) mea-

surement of sampling adequacy and Bartlett’s test of sphe-

ricity were used to determine whether or not the data were

appropriate for factor analysis.

Cronbach’s alpha coefficient was evaluated. Cronbach’s

alpha is an index of the degree to which a measuring instru-

ment is internally reliable. If the dimensions included less

than three items, Spearman’s rank correlation coefficient was

calculated.

The predictors of non-HPV vaccination were determined

by logistic multivariate regression models, using non-HPV

vaccination as the dependent variable.

Logistic regressions were conducted using the variables

that were found to be statistically significant on bivariate

analysis. The measure of association was calculated using

adjusted odds ratios (OR) and 95% confidence intervals (CI).

Estimates were made using STATA Version 11.0 (StataCorp

LP, College Station, TX, USA) and statistical significance was

set at two-tailed a < 0.05.

Results

The total number of survey participants was 2007 female

university students. The participation rate was 88.9%, and the

percentage of non-vaccinated individuals was 71.7%.

The distribution of the study population according to the

sociodemographic and health-related variables and the

proportion of non-vaccinated individuals according to these

variables are shown in Table 2. Most participants were aged

between 18 and 20 years (61.9%). The percentage of non-

vaccination was higher among participants aged 21e26

years compared with those aged 18e20 years, and higher

among employed participants compared with unemployed

participants (75.4% vs 70.5%). In terms of the health-related

variables, the percentage of non-vaccinated individuals

was higher among smokers (75.7% vs 70.3%), participants

who had never visited a gynaecologist (78.8% vs 68%),

participants who never used condoms (74.1% vs 70.7%),

participants who had experienced sexual intercourse (72.3%

vs 69.93%), and participants in a stable relationship (73.7% vs

68.9%).

The result of the confirmatory factor analysis showed that

the Kaiser-Meyer-Olkin value was 0.70, indicating that the

sample size was adequate for principal component analysis.

Similarly, the results obtained fromBartlett’s test of sphericity

(P ¼ 0.000) indicated that the variables were correlated and therefore suitable for factor analysis. Six factors with Eigen

values >1 and a cumulative percentage of explained variance

of 62.2% were analysed further. The total Cronbach’s alpha

was 0.68, ranging between 0.60 and 0.75. Moreover, there were

14 items about the perception of severity, susceptibility, gen-

eral barriers, vaccination barriers, general benefits and spe-

cific benefits.

Table 3 shows the bivariate analysis based on the HBM. The

participants who had high scores for ‘perceived general bar-

riers’ (OR 1.67, 95% CI 1.51e1.85) and ‘perceived vaccination

barriers’ (OR 1.66, 95% CI 1.44e1.92) were more likely to be

unvaccinated. Also, those who had high scores for ‘no

perceived general benefits’ (OR 1.97, 95% CI 1.66e2.34) and ‘no

perceived specific benefits’ (OR 2.77, 95% CI 2.34e3.29) were

more likely to be unvaccinated. The total score for all the di-

mensions showed that participants with higher scores were

2.56 times more likely to be unvaccinated.

Table 4 describes the adjusted ORs and 95% CIs obtained

with the multivariate logistic model in which non-HPV

vaccination was the dependent variable. After adjusting for

all other covariates, the dimensions associated with non-HPV

Table 3eAnalysis of attitudes based on the Health Belief Model dimensions among a sample of female university students in Athens.

Dimensions of the HBM Item numbers included in the HBM dimensions

Alpha Range Mean (SD) OR 95% CI

No perceived general benefits I-1 to I-4 0.65 1-5 2.41 (0.62) 1.97 1.66e2.34

No perceived specific benefits I-5 to I-7 0.75 1-5 2.83 (0.69) 2.77 2.34e3.29

Perceived general barriers I-8, I-9 0.86a 1-5 3.15 (1.03) 1.67 1.51e1.85

Perceived barriers to vaccination I-10 to I-12 0.60 1-5 2.14 (0.75) 1.66 1.44e1.92

No perceived susceptibility I-13 e 1-5 3.84 (0.93) 0.91 0.82e1.05

No perceived severity I-14 e 1-5 1.90 (0.85) 1.07 0.96e1.21

Total I-1 to I-14 0.68 1-5 2.62 (0.40) 2.56 2.24e3.00

SD, standard deviation; OR, odds ratio; CI, confidence interval. a Rank correlation coefficient.

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3 271

vaccination in the bivariate analysis remained significant.

University students who had high scores for ‘perceived gen-

eral barriers’, ‘perceived vaccination barriers’, ‘no perceived

general benefits’, ‘no perceived specific benefits’ and ‘no

general benefits’ were more likely to be unvaccinated. The

multivariate model found that being in a stable relationship,

being employed, being a smoker and never having visited

a gynaecologist increased the probability of non-HPV

vaccination.

Table 4 e Predictors of non-human papillomavirus vaccination adherence among a sample of female university students in Athens.

Variables Adjusted OR 95% CI

Relationship status Non-stable

relationship

1

Stable relationship 1.51 1.16e1.95

Have you ever

visited a

gynaecologist?

Yes 1

No 1.74 1.30e2.35

Employment status No 1

Yes 1.37 1.02e1.83

Smoking status Non-smoker 1

Smoker 1.36 1.03e1.80

Perceived

general barriers

1.52 1.34e1.71

Perceived barriers

to vaccination

1.40 1.17e1.66

No perceived

general benefits

1.28 1.03e1.59

No perceived

specific benefits

2.18 1.78e2.66

OR, odds ratio; CI, confidence interval.

Adjusted OR and 95% CI estimated using multivariate logistic

regression. Variables included in the model were those found to

have a significant association on bivariate analysis.

Discussion

This study investigated the reasons for refusal of the HPV

vaccine among female university students, and explored their

perceptions and attitudes using the HBM.

According to health-related variables, being in a stable

relationship was a positive predictor of non-HPV vaccination

(OR 1.51, 95% CI 1.16e1.95). This is consistent with two US

studies.11,19 Likewise, smokers were more likely to refuse the

HPV vaccine (OR 1.36, 95%CI 1.03e1.80), and this could suggest

that less healthy lifestyle behaviours reflect lower participa-

tion in preventive practices.20 Rosenthal et al. and Tiro et al.,

who conducted surveys in the USA among youngwomen aged

between 19 and 26 years and parents of adolescent girls aged

between 12 and 17 years and young women aged 18e27 years

respectively, confirmed that those students who had never

visited a gynaecologist were more likely to report non-HPV

vaccination; the present survey agreed with this finding (OR

1.74, 95% CI 1.30e2.35).21,22 This study used a theory-informed

approach, assessing attitudes to HPV vaccination based on the

HBM.

According to the items based on HBM constructs, the par-

ticipants with a high score for ‘perceived general barriers’

(lack of information about the vaccine) were more likely to

refuse the vaccination; this is in agreement with studies by

Liddon et al., Mortensen et al. and Juntasopeepun

et al.8,10,17,23,24 Additionally, participants with a high score for

‘vaccination barriers’ (cost of vaccination and lack of social

security) were more likely to be unvaccinated. This result is

consistent with other studies.8,16,17,19,23e25 In addition, par-

ticipants with a high score for ‘no general benefits’ (general

perceptions about vaccinations) were more likely to be un-

vaccinated. This finding is in agreement with Marlow et al.9

Similar to other studies, this study found that participants

with a high score for ‘no specific benefits’ (safety and efficacy

of HPV vaccination) were more likely to be unvaccinated (OR

2.18, 95% CI 1.78e2.66).5,8,11,15e17,19,23,26 Worldwide, several

previous studies have demonstrated barriers to HPV vacci-

nation among young adult women. Common barriers include

lack of information and knowledge about HPV vaccine, poor

perceived risk of acquiring HPV infection, misconceptions

about safety, and the cost of HPV vaccination.5,8e17,27 Evalua-

tion of the perceptions about benefits, barriers, severity and

susceptibility of HPV vaccine may be key to the development

of targeted educational campaigns. Healthcare providers play

an influential role in decisions regarding vaccination.8 The

correct information and the strength of their recommenda-

tion would change the intention to uptake the vaccine. Im-

munization is recognized as a powerful public health tool in

disease control and eradication. Registered nurses are the

main health professionals responsible for vaccine adminis-

tration. Registered nurses often provide leadership in

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3272

developing and maintaining a high-quality programme.28

Nurse practitioners play a key role in preventing HPV infec-

tion. Their role in HPV education, prevention and vaccination

is essential. In particular, school nurses may reduce health

inequalities in delivery of the HPV programme.29,30 Further-

more, the role of oncology nurses as educators and advocates

regarding HPV vaccination is crucial for successful acceptance

of this vaccine.31 Public health educational programmes

focussing on risk perceptions, benefits of knowledge and at-

titudes about the HPV vaccine, accurate information and

financial support would improve vaccination uptake. If there

is widespread uptake, HPV vaccination will play a crucial role

in reducing the burden of cervical cancer.25 The main

strengths of this study were the large, representative sample

size, and the focus on female university students who remain

an important target group for vaccination.32

The findings of this survey should be interpreted in light of

its limitations. First, this was a cross-sectional survey, so

causality cannot be inferred. Second, the study was based on

self-reported information, so personal perceptions may have

been overestimated, although self-reporting is a cost-effective

and feasible method for gathering data from large population

samples. Third, the survey sample only included university

students. These students have a higher level of education and

are more knowledgeable; as such, the results cannot be

extrapolated to the general female population. Fourth, the

participation rate was 88.9%; therefore, the possibility of non-

response bias should be taken into consideration. Finally,

conclusions about correlation between intention and reasons

for being unvaccinated should be interpreted with caution, as

the reasons for being unvaccinated may have changed since

the time of data collection.8

In conclusion, this study demonstrated the utility of HBM

constructs of perceived barriers and benefits in understanding

intentions to receive the HPV vaccine. Participants who had

general negative perceptions about vaccination, lack of in-

formation about the HPV vaccine and its cost, and mis-

conceptions about HPV vaccination were less likely to be

vaccinated. There is an urgent need to improve health pro-

motion and information campaigns to enhance the benefits

and reduce the barriers to HPV vaccination in Greece.

Author statements

Ethical approval

The questionnaire was anonymous and was approved by the

Ethics Committee of the University of Athens. All universities

gave permission for the questionnaire to be administered, and

written informed consent was obtained from all participants.

Funding

None declared.

Competing interests

None declared.

r e f e r e n c e s

1. Marek E, Dergez T, Kricskovics A, Kovacs K, Rebek-Nagy G, Gocze K, Kiss I, Ember I, Gocze P. Difficulties in the prevention of cervical cancer: adults’ attitudes towards HPV vaccination 3 years after introducing the vaccine in Hungary. Vaccine 2011;29:5122e9.

2. Montgomery K, Smith-Glasgow ME. Human papillomavirus and cervical cancer knowledge, health beliefs, and preventive practices in 2 age cohorts: a comparison study. Gend Med 2012;9:55e66.

3. Garland SM, Smith JS. Human papillomavirus vaccines: current status and future prospects. Drugs 2010;70:1079e98.

4. Mammas IN, Vageli D, Spandidos DA. Geographic variations of human papilloma virus infection and their possible impact on the effectiveness of the vaccination programme. Oncol Rep 2008;20:141e5.

5. Bakogianni GD, Nikolakopoulos KM, Nikolakopoulou NM. HPV vaccine acceptance among female Greek students. Int J Adolesc Med Health 2010;22:271e3.

6. Tsakiroglou M, Bakalis M, Valasoulis G, Paschopoulos M, Koliopoulos G, Paraskevaidis E. Women’s knowledge and utilization of gynecological cancer prevention services in the Northwest of Greece. Eur J Gynaecol Oncol 2011;32:178e81.

7. Donadiki EM, Jiménez-Garcı́a R, Hernández-Barrera V, Carrasco-Garrido P, López de Andrés A, Velonakis EG. Human papillomavirus vaccination coverage among Greek higher education female students and predictors of vaccine uptake. Vaccine 2012;30:6967e70.

8. Liddon NC, Hood JE, Leichliter JS. Intent to receive HPV vaccine and reasons for not vaccinating among unvaccinated adolescent and young women: findings from the 2006e2008 National Survey of Family Growth. Vaccine 2012;30:2676e82.

9. Marlow LAV, Waller J, Evans REC, Wardle J. Predictors of interest in HPV vaccination: a study of British adolescents. Vaccine 2009;27:2483e8.

10. Sotiriadis A, Dagklis T, Siamanta V, Chatzigeorgiou K, Agorastos T, LYSISTRATA Study Group. Increasing fear of adverse effects drops intention to vaccinate after the introduction of prophylactic HPV vaccine. Arch Gynecol Obstet 2012;285:1719e24.

11. Hopfer S, Clippard JR. College women’s HPV vaccine decision narratives. Qual Health Res 2011;21:262e77.

12. Mehu-Parant F, Rouzier R, Soulat JM, Parant O. Eligibility and willingness of first-year students entering university to participate in a HPV vaccination catch-up program. Eur J Obstet Gynecol Reprod Biol 2010;148:186e90.

13. Gottvall M, Larsson M, Hoglund AT, Tydén T. High HPV vaccine acceptance despite low awareness among Swedish upper secondary school students. Eur J Contracept Reprod Health Care 2009;14:399e405.

14. Donati S, Giambi C, Declich S, Salmaso S, Filia A, Ciofi Degli Atti ML. Knowledge, attitude and practice in primary and secondary cervical cancer prevention among young adult Italian women. Vaccine 2012;30:2075e82.

15. Jain N, Euler GL, Shefer A, Lu P, Yankey D, Markowitz L. Human papillomavirus (HPV) awareness and vaccination initiation among women in the United States, National Immunization Survey e adult 2007. Prev Med 2009;48:426e31.

16. Ratanasiripong NT. A review of human papillomavirus (HPV) infection and HPV vaccine-related attitudes and sexual behaviors among college-aged women in the United States. J Am Coll Health 2012;60:461e70.

17. Juntasopeepun P, Suwan N, Phianmongkhol Y, Srisomboon J. Factors influencing acceptance of human papillomavirus vaccine among young female college students in Thailand. Int J Gynaecol Obstet 2012;118:247e50.

p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 2 6 8e2 7 3 273

18. Coe AB, Gatewood SB, Moczygemba LR, Goode JV, Beckner JO. The use of the Health Belief Model to assess predictors of intent to receive the novel (2009) H1N1 influenza vaccine. Inov Pharm 2012;3:1e11.

19. Weiss TW, Rosenthal SL, Zimet GD. Attitudes toward HPV vaccination among women aged 27 to 45. ISRN Obstet Gynecol 2011;2011:670318. http://dx.doi.org/10.5402/2011/670318.

20. Manhart LE, Burgess-Hull AJ, Fleming CB, Bailey JA, Haggerty KP, Catalano RF. HPV vaccination among a community sample of young adult women. Vaccine 2011;29:5238e44.

21. Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine among women aged 19e26: importance of a physician’s recommendation. Vaccine 2011;29:890e5.

22. Tiro JA, Tsui J, Bauer HM, Yamada E, Kobrin S, Breen N. Uptake and correlates of the human papillomavirus vaccine among adolescent girls and young adult women: an analysis of the 2007 California Health Interview Survey. J Womens Health (Larchmt) 2012;21:656e65.

23. Zimet GD, Weiss TW, Rosenthal SL, Good MB, Vichnin MD. Reasons for non-vaccination intentions among 19e26-year- old women. BMC Womens Health 2010;10:27.

24. Mortensen GL. Drivers and barriers to acceptance of human papillomavirus vaccination among youngwomen: a qualitative and quantitative study. BMC Public Health 2010;10:68.

25. Allen JD, Mohllajee AP, Shelton RC, Othus MK, Fontenot HB, Hanna R. Stage of adoption of the human papillomavirus vaccine among college women. Prev Med 2009;48:420e5.

26. Marlow LAV. HPV vaccination among ethnic minorities in the UK: knowledge, acceptability and attitudes. Br J Cancer 2011;105:486e92.

27. Chan ZC, Chan TS, Ng KK, Wong ML. A systematic review of literature about women’s knowledge and attitudes toward human papillomavirus (HPV) vaccination. Public Health Nurs 2012;29:481e9.

28. Lin JC, Wang T. Criminal liability research in vaccine administration by public health nurse: a case study of the Nantou vaccine administration case. J Nurs Res 2008;16:1e7.

29. Boyce T, Holmes A. Addressing health inequalities in the delivery of the human papillomavirus vaccination programme: examining the role of the school nurse. PLoS One 2012;7:e43416.

30. Daley AM. Providing adolescent-friendly HPV education. Nurse Pract 2011;36:35e40.

31. Buick C, Metcalfe K. The human papillomavirus vaccine: an oncology nursing issue. Can Oncol Nurs J 2009;19:60e4.

32. Licht AS, Murphy JM, Hyland AJ, Fix BV, Hawk LW, Mahoney MC. Is use of the human papillomavirus vaccine among female college students related to human papillomavirus knowledge and risk perception? Sex Transm Infect 2010;86:74e8.

  • Health Belief Model applied to non-compliance with HPV vaccine among female university students
    • Introduction
    • Methods
      • Statistical analysis
    • Results
    • Discussion
    • Author statements
    • Ethical approval
    • Funding
    • Competing interests
    • References