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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.
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- 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