Healthcare EducationTranslating self-persuasion into an adolescent HPV vaccine promotion intervention for parents attending safety-net clinics
Introduction
Self-persuasion, the process of generating one’s own arguments for performing a behavior, is an effective behavior change strategy [1], [2], [3], [4], [5]. Approaches to self-persuasion have improved health behaviors including smoking cessation, dietary behaviors, and safer sex practices [1], [2], [3], [4], [6], [7]. However, such approaches have not been developed for use in U.S. safety-net clinics whose mission is to care for medically underserved populations (uninsured, low-income, less educated) [8], [9], [10]. Nor has self-persuasion been developed to promote the human papillomavirus (HPV) vaccine. This study’s purpose was to demonstrate feasibility and examine effects of a parent-targeted, self-persuasion intervention promoting adolescent HPV vaccination in a safety-net clinic setting.
U.S. adolescent HPV vaccination is suboptimal [11] and is a behavior for which self-persuasion may be particularly effective. One reason for suboptimal rates is that many parents-primary decision-makers for adolescent immunization-remain undecided or ambivalent about the vaccine, even with a provider recommendation [12], [13], [14], [15], [16]. Undecided parents are a heterogeneous group: some perceive low risk or poor vaccine efficacy; others are concerned about promoting sex, unknown side effects, or are simply unmotivated [12], [17]. By leveraging parents’ own arguments for HPV vaccination, a self-persuasion intervention may efficiently deliver personally relevant arguments for the vaccine [7] and effectively address parental indecision.
Self-persuasion interventions have typically been used among well-educated populations [1], [2], [3], [4], [6] by either writing [3], [4], [6] or verbalizing arguments [3], but have not been implemented among diverse underserved populations seen in safety-net clinics. Before a self-persuasion HPV vaccine intervention can be tested in safety-net clinics, two feasibility issues needed to be addressed. First, whether safety-net populations with lower education and literacy levels [18], [19], [20] can perform the self-persuasion tasks (generate and verbally articulate their own reasons for HPV vaccination). Second, whether the self-persuasion tasks can be performed by parents with different demographic characteristics (preferred language, sex of the adolescent). Before this study, no self-persuasion procedures had been developed in Spanish. Also, it was unclear whether parents of boys (compared to girls) might struggle in generating reasons for HPV vaccination because parental awareness of the causal link between HPV infection and cervical cancer is higher than for anal, penile, and oropharyngeal cancers (i.e., cancers affecting males) [21].
We developed and tested a tablet-based (iPad) application instructing parents to verbally complete two self-persuasion tasks: 1) answer questions about the vaccine to brainstorm different reasons for vaccination; and 2) summarize, in their own words, reasons for the vaccine that are important to them. We hypothesized that completing tasks via a tablet-based application would be a feasible strategy for use in safety-net clinics because the voiceover narration in the application circumvents potential literacy concerns and the tablet’s audio-recording function facilitate self-administration of the tasks. To assess feasibility among parents of adolescents attending safety-net clinics, we conducted cognitive interviews gathering quantitative and qualitative data and addressed the following research questions (RQ):
(RQ1) Did participants like the application and would they be interested in using it in clinic?
(RQ2) Which question prompts helped parents generate reasons for the HPV vaccine while not raising vaccine concerns?
(RQ3) Were participants’ able to verbalize reasons for HPV vaccination?
(RQ4) Did performing the self-persuasion tasks shift parents’ decisions about the vaccine?
We also explored the extent to which participants’ performance of tasks and evaluations of the application varied across language (Spanish, English) and sex of the adolescent.
Section snippets
Participants
Eligible participants included parents of patients (ages 11–17) attending safety-net pediatric clinics in Dallas, Texas. Exclusion criteria included no telephone access, impaired hearing or speech, or adolescent who was pregnant. We sampled parents of unvaccinated and vaccinated children (3:1 ratio) to gather a full range of evaluations on the self-persuasion tasks. Potential participants were identified via electronic medical records (EMR), mailed an invitation letter, and called to confirm
Sample characteristics
Most participants were Hispanic (68.9%) and had a high school education or less (64.4%), indicated Spanish as their primary language (53.3%), and completed the self-persuasion tasks about a male adolescent (57.7%; Table 1). Nearly all participants (97.7%) were mothers or female guardians.
Reactions to using the tablet (RQ1)
Participants liked using the tablet and would be interested in using it at a clinic visit. Although some indicated concern about verbalizing responses in the waiting room and preferred a more private area.
Quantitative findings
Discussion
In this formative study, we demonstrated that Spanish- and English-speaking parents of boys and girls seen in safety-net clinics were able to use a tablet-based application to answer different questions about the HPV vaccine and verbalize their own reasons for having their child vaccinated, tasks critical to a self-persuasion intervention. Overall, these novel findings demonstrated feasibility in a low-income, less educated population, as the two self-persuasion tasks were seen as helpful and
Conflict of interest
All authors declare no conflict of interest.
Acknowledgements
All phases of this study were supported by a grant funded by the National Cancer Institute (PIs: Tiro & Baldwin; 1R01CA178414). Additional support provided by the UTSW Center for Translational Medicine, through the NIH/National Center for Advancing Translational Sciences (UL1TR001105) and the Simmons Comprehensive Cancer Center (1P30 CA142543), and the UT Southwestern Center for Patient-Centered Outcomes Research (PCOR) through the Agency for Healthcare Research and Quality (R24 HS022418). Dr.
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