Article

Evaluating a Technology-Mediated HPV Vaccination

Awareness Intervention: A Controlled,
Quasi-Experimental, Mixed Methods Study
Heather M. Brandt 1, * , Beth Sundstrom 2 , Courtney M. Monroe 1 ,
Gabrielle Turner-McGrievy 1 , Chelsea Larsen 3 , Melissa Stansbury 3 , Karen Magradey 3 ,
Andrea Gibson 4 and Delia Smith West 3
1 Department of Health Promotion, Education, and Behavior, Arnold School of Public Health,
University of South Carolina, Columbia, SC 29208, USA; cmmonroe@mailbox.sc.edu (C.M.M.);
mcgrievy@mailbox.sc.edu (G.T.-M.)
2 Department of Communication, College of Charleston, Charleston, SC 29424, USA; sundstrombl@cofc.edu
3 Department of Exercise Science, Arnold School of Public Health, University of South Carolina,
Columbia, SC 29208, USA; calarsen@email.sc.edu (C.L.); stansbm@email.sc.edu (M.S.);
magradey@mailbox.sc.edu (K.M.); westds@mailbox.sc.edu (D.S.W.)
4 South Carolina Office of Rural Health, Lexington, SC 29072, USA; gibson@scorh.net
* Correspondence: hbrandt@sc.edu; Tel.: +1-803-777-7096




Received: 14 November 2020; Accepted: 8 December 2020; Published: 10 December 2020


Abstract: College-aged women and men are an important catch-up population for human
papillomavirus (HPV) vaccination interventions. Limited research has explored technology-mediated
HPV vaccination awareness interventions aimed at college students. The purpose was to evaluate a
novel, technology-mediated, social media-based intervention to promote HPV vaccination among
college students. A controlled, quasi-experimental, mixed methods study examined the feasibility of
a technology-based intervention among two undergraduate classes (n = 58) at a public university in
the southeastern United States of America. Classes were randomized to receive one of two cancer
prevention programs (i.e., HPV vaccination (intervention) or healthy weight (control)). Both programs
contained eight technology-mediated sessions, including weekly emails and private Facebook
group posts. Participants completed pre-/post-test surveys and submitted weekly qualitative
reflections. Data were analyzed using descriptive statistics and thematic review for qualitative
data. Knowledge improved among participants in the HPV vaccination intervention relative to
those in the control condition. Participants (97%) interacted on Facebook by “liking” a post or
comment or posting a comment. Participants demonstrated robust engagement and high treatment
satisfaction. Results suggests that social media is an effective platform to reach college students
with health promotion interventions and increase HPV vaccination awareness in this important
catch-up population.

Keywords: human papillomavirus vaccination; cancer prevention; college students; social media;
behavior change; health promotion intervention

1. Introduction
Human papillomavirus (HPV) is pervasive and almost all men and women will contract it at some
point in their lifetime [1]. HPV is the most common sexually transmitted infection (STI) in the United
States (U.S.), and college students are at high risk for STIs. Young people, aged 15–24, account for
almost half (49%) of new HPV infections in the U.S. [2]. In most cases, HPV infections clear without
treatment; however, the virus can lead to genital warts and cancers in men and women, including

Vaccines 2020, 8, 749; doi:10.3390/vaccines8040749 www.mdpi.com/journal/vaccines

Vaccines 2020, 8, 749 2 of 15

cancers of the cervix, vulva, vagina, penis, and anus, and oropharyngeal cancer [3]. In 2015, there were
43,371 new cases of HPV-associated cancer in the U.S., with oropharyngeal cancer, which is more than
twice as common in men, surpassing cervical cancer as the most common HPV-related cancer [4].
HPV vaccinations have been licensed by the Food and Drug Administration (FDA) since 2006 in
the U.S. The currently available vaccine in the U.S., Gardasil® 9, prevents up to 90% of HPV-related
cancers [5]. HPV vaccines are effective and have significantly reduced rates of genital warts,
HPV infections, and cervical lesions among women [6]. A recent surveillance study found evidence of
HPV vaccine effectiveness and herd immunity among young women [7]. The Advisory Committee on
Immunization Practices (ACIP) recommends a two-dose HPV vaccination series for both boys and girls
between 11 and 12 years of age; however, in the U.S., uptake of the HPV vaccine is slow. From 2016
to 2017, HPV vaccination initiation among adolescents aged 13–17 increased from 60.4% to 65.5%,
yet only 48.6% of adolescents were up-to-date with the HPV vaccine series in 2018 [8]. For adolescents
and young adults who missed HPV vaccination at earlier ages (ages 15–26), the ACIP recommends a
three-dose HPV vaccination series for women aged 15 to 26, men up to 21 years, and men ages 22–26
who have sex with men. HPV vaccination rates are particularly low in South Carolina, with only 42.7%
of adolescents receiving the complete vaccine series (compared with 48.6% in the U.S.) [8]. Furthermore,
South Carolina lags behind the U.S. among those receiving at least one dose of the HPV vaccine series
(59.6% vs. 65.5%, respectively) [8]. Slow uptake of HPV vaccination results in a large population of
college-aged men and women who are partially vaccinated or unvaccinated; this population constitutes
what is commonly referred to as a “catch up” population (also called late vaccination). College-age
women and men are at increased risk of acquiring HPV and are considered an important catch-up
population for HPV vaccination [9,10].
Transitions from high school to young adulthood have been identified as a critical period to
institute health-promoting behaviors [11]. College students are a critical population to target for HPV
vaccine awareness and completion as these young adults begin to assume increased responsibility and
independence surrounding healthcare decisions. Initial efforts to increase knowledge and awareness
about HPV and appropriate vaccination practices have indicated promise, but point to the need for
additional efforts to promote broader intentions to change and greater vaccine uptake [12–17].
Technology provides an attractive platform for HPV vaccination awareness interventions targeting
college students because it is ubiquitous in their everyday lives. Nearly 100% of undergraduate college
students use the internet [18]. Since 2013, internet use among young adults ages 18–29 years has
remained at 97% or higher [19]. Furthermore, approximately 94% own a smartphone, 88% use social
media [20], and 80% report using Facebook [21]. Behavioral interventions increasingly employ social
media to improve awareness and vaccination coverage [22]. Recent studies have investigated HPV
vaccination communication online through social platforms, including YouTube [23], Twitter [24],
and Facebook [25]. Online messages about HPV vaccination include sensational and negative posts
that may perpetuate misleading coverage and lead to insufficient information [23,25]. Therefore,
effective online communication about HPV vaccination is needed to counter the dissemination of
manipulative and false messages.
Interventions to increase HPV vaccination have historically targeted parents and health care
providers [26–28]. However, a growing number of HPV vaccination interventions target young
women and college students to increase vaccination rates among vaccine-eligible and catch-up
populations [29–35]. Only a small number of HPV vaccination awareness interventions have employed
social media, despite the dynamic potential and widespread reach of this platform [36–40]. A recent
study found that a Facebook-assisted cervical cancer prevention discussion was more effective than
an in-person discussion [41]. There is a clear opportunity for the development and evaluation of
technology-based HPV vaccination interventions targeting college students.
The purpose of this study was to examine a novel, technology-mediated HPV vaccination
awareness intervention for college students. Targeting college students during this transitional and
formative period offers an opportunity to increase awareness and promote cancer prevention. The goal
Vaccines 2020, 8, 749 3 of 15

of this intervention was to encourage those in the catch-up population who had not yet completed
vaccination to obtain the full HPV vaccine series.

2. Materials and Methods

2.1. Study Design and Procedures

A controlled, quasi-experimental, mixed methods study examined the feasibility of a
technology-based intervention among two undergraduate classes at a public university in the southeast
region of the U.S. This study included the implementation and evaluation of two health promotion
and cancer prevention programs relevant to college students. Classes were randomized by coin flip
to receive either an HPV vaccination awareness intervention or a behavioral weight gain prevention
intervention (Healthy Weight; control). Each group served as the control for the other group,
allowing for simultaneous intervention comparisons. The intervention was adapted from a successful
theory-based health communication campaign, It’s My Time [42]. The study design and results from
the Healthy Weight intervention arm have been published previously [43].
Both interventions included 8 technology-mediated health promotion sessions over 9 weeks,
which included weekly emails, as well as private Facebook group posts. Study personnel posted
to the private Facebook message board at least 5 times each week. Posts were scheduled to allow
automated distribution through a social media management tool (Hootsuite Media Inc., Vancouver,
BC, Canada) to ensure consistent delivery of content. Each group received the same schedule
of email newsletters disseminated automatically using MailChimp (Rocket Science Group, LLC,
Atlanta, GA, USA), which offered prescheduled distribution and tracked newsletter open rate.
Participants completed a weekly open-ended reflection about the intervention emails and Facebook
posts, which encouraged students to describe what factors influenced their personal engagement with
the intervention. Posttreatment questionnaire data were obtained 9 weeks after intervention initiation.
Detailed descriptions of the HPV and control groups are provided below.
This study was approved by the Institutional Review Boards at the College of Charleston and the
University of South Carolina.

2.2. Participant Recruitment and Eligibility

Undergraduate students enrolled in an advanced health communication course were recruited via
email. Students elected to voluntarily participate in the study or complete an alternative assignment
for course credit. Students were not graded on engagement with the intervention. A description of the
study and criteria for eligibility were provided. To be eligible, students were required to be registered
in the course, have internet access on a computer or mobile device, and be willing to establish or use
their current email address and Facebook account. Informed consent was provided via secure website
by all students prior to participation.
All otherwise eligible college students enrolled in the two designated classes included in the study
were eligible to participate, including those below the age of 18 years, so as to minimize any stigma
or segregation of those college students who might not yet have turned 18 years of age. A waiver of
parental permission for participation was requested and approved for those individuals below the age
of 18 based on the minimal risk to the subjects associated with participation in the study and the lack
of any adverse effects on the rights or welfare of the subjects, coupled with the difficulty in practically
carrying out the project without this waiver. Because the selected courses were upperclass courses
designed for college students further along in their studies, it was anticipated that there would not
be any children below the age of 18. All participants were asked to sign (electronically) an informed
consent form that was approved by the College of Charleston Institutional Review Board.
Vaccines 2020, 8, 749 4 of 15

2.3. HPV Vaccination Awareness Intervention

The HPV vaccination intervention was based on the health belief model [44,45], the transtheoretical
model [46], and adapted content from the successful theory-based health communication campaign,
It’s My Time [42]. It’s My Time was developed through formative audience research and an
academic-community collaboration to implement and evaluate a peer-based intervention. Formative
research showed that preventing cancer is not a motivating message (or perceived benefit) to young
adults. Therefore, the main message of It’s My Time encouraged participants to consider receiving the
HPV vaccination so that they have time to pursue their dreams. Messages reinforced the concept of
college students embracing their own time and time for themselves rather than emphasizing cancer
risk-based messaging. A secondary message reminded students that it is not too late to receive the
HPV vaccination or take control of their health [42].
These messages and health education information were incorporated into content that was
delivered by weekly electronic newsletters and interactive Facebook posts in the current study.
College students report limited knowledge of HPV and HPV-related cancer, coupled with high levels
of concern about STIs [30,33,42,47]. Therefore, a key strategy of the intervention was to increase
the perceived severity (i.e., the negative consequences) of contracting HPV and increase perceived
susceptibility of acquiring HPV [26,31,34,42]. Campaign messages emphasized college students
pursuing their interests and dreams with the time they gained from preventing HPV and HPV-related
cancer. This approach aligns with current research that successful narrative messages depend on the
perceived relevance of the storyline to the audience [31,48].
Lesson content focused on themes relevant to college students contemplating HPV vaccination
(see Table 1). Messages were tailored to the campus and local area, with resources for how and where
to obtain the HPV vaccination at low or no cost, including the university’s Student Health Services.
Study investigators moderated the Facebook page, which included providing answers to questions and
stimulating interaction, as well as sharing timely news articles and studies related to HPV vaccination.
The posts were designed to cultivate a social climate of support for considering initiation of the
vaccination series (or completion of the series for those who had partial completion of the sequence).
Polls provided social norming to stimulate vaccination-related discussion. Intervention activities
(e.g., reading the newsletters and interacting on Facebook) were intended to require approximately
30 total minutes per week. The program spanned a 9-week period during the spring semester, with a
hiatus during spring break week.

Table 1. Weekly lesson topics delivered through electronic newsletters and Facebook posts.

Session Topics
1 What is HPV?
2 Am I at risk for HPV?
3 How do I prevent HPV?
4 How do I know if I have HPV?
5 What are the risks and benefits of HPV vaccination?
6 Should I get the HPV vaccine?
7 Where do I go to get the HPV vaccine?
8 Why do I need 3 doses?

2.4. Control Intervention

Similar intervention components were used for the control intervention. The control group received
a Healthy Weight intervention, which included 8 electronic newsletters and a minimum of 5 postings
per week to a separate, private Facebook group moderated by study staff to increase knowledge and
support of healthy eating, activity, and weight control practices. Intervention content was derived
from social cognitive theory [49] and established behavioral weight control programs, such as the
Diabetes Prevention Program Lifestyle Intervention [50]. Emphasis was placed on key behavioral
Vaccines 2020, 8, 749 5 of 15

strategies for healthy eating and physical activity (e.g., goal-setting, self-monitoring, overcoming
barriers, relapse prevention, and social support). Students were encouraged to take 10,000 steps/day
and were provided with electronic tools for objectively monitoring their physical activity and weight
(Fitbit Zip and Aria Wi-Fi-enabled scale, respectively; Fitbit Inc., Boston, MA, USA). The HPV and
control interventions were matched on duration, structure, and number of planned contacts. However,
the control intervention did not receive content related to HPV awareness or vaccination.

2.5. Measures
Participants completed assessments at baseline and post-intervention at 9 weeks. Questionnaires
were administered online for all self-reported measures (Qualtrics, Provo, UT, USA).

2.5.1. Sociodemographic Characteristics

Demographic characteristics were self-reported at baseline and included age, sex, race,
and academic year. Sociodemographic characteristics included health insurance status, age at sexual
debut, number of sex partners, gender of sex partners, relationship status, and contraceptive method.

2.5.2. HPV Vaccination Knowledge, Attitudes, Beliefs and Behaviors

The current study adapted validated measures from Patel and colleagues [51], the 2013 Health
Information National Trends Survey (HINTS), and the 2013 Behavioral Risk Factor Surveillance
System (BRFSS). Survey items measured knowledge and awareness of HPV and HPV vaccination
(e.g., “Some types of HPV can cause genital warts”; “People who have been infected with HPV might
not have symptoms”), factors influencing the decision to be vaccinated (e.g., concerns about getting
HPV, recommendation by a healthcare provider), and intention to seek HPV vaccination. In addition,
students were queried about how many vaccines in the series they had received to date and, for those
who had not yet completed the series, their intentions to seek out the vaccine.

2.5.3. Intervention Engagement

HPV intervention engagement was assessed objectively on web-based platforms (MailChimp and
Facebook). Engagement with HPV newsletters was defined as the number of students who opened
the newsletter each week, which was obtained from MailChimp metrics. Engagement with the HPV
Facebook group was measured by the number of interactions, including post likes, comments, and
original posts. Interactions were aggregated for the week and tallied by research staff; the average
number of interactions per week was determined.

2.5.4. Treatment Satisfaction

At the conclusion of the intervention, students reported how satisfied they were with the
HPV program by rating its overall usefulness and likelihood of recommending it to a friend or
relative. Level of satisfaction with specific intervention components (e.g., number of sessions,
frequency, and length of Facebook group postings) was also reported. All items were rated on an
agreement-oriented 7-point Likert scale anchored with strongly agree and strongly disagree.

2.5.5. Weekly Reflections

Participants received a weekly web-based survey inviting them to write a reflection critiquing the
efficacy of each week’s materials and messages, including recommendations for improvement. Students
were prompted to reflect on “how interesting”, “how useful”, and “how engaging” the newsletter and
Facebook posts were each week. They were asked to provide specific examples and to incorporate
concepts and theories from assigned readings and course discussions into their reflections.
Vaccines 2020, 8, 749 6 of 15

2.6. Statistical Analysis

Descriptive statistics were used for all baseline and engagement measures. Analysis of treatment
satisfaction aggregated agree, somewhat agree, and strongly agree responses, and combined disagree,
somewhat disagree, and strongly disagree, and descriptive data are provided. One sample test of
proportions was used to determine whether there was a significant difference in knowledge from
pre-post for each group, and two sample test of proportions was used to determine whether there
was a significant difference between the change in knowledge from pre-post between the two groups.
A p value of less than 0.05 was used to determine statistical significance. All statistical analyses were
performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA).
Qualitative data analysis of the open-ended weekly reflections was conducted using a constant
comparative method [52], employing analytic tools recommended by Corbin and Strauss (2008) to ensure
quality data coding. First, one author coded reflections line-by-line, which allowed new concepts to
emerge. Then, a codebook was developed based on emergent concepts. Next, axial coding identified
patterns and cross-cutting concepts. Researchers met frequently throughout the implementation and
evaluation of the intervention and reached unanimous consensus on patterns, themes, and conclusions
emerging from the data.

3. Results

3.1. Sample Characteristics

We utilized a convenience sampling approach. All registered students in two sections of the
advanced health communication class were eligible for and chose to enroll in the study. Each section
had 29 students. Participants (n = 58) included juniors and seniors with a median age of 21.6 ± 2.2 years.
Most participants self-identified as female (81%) and white (90%). Most participants reported health
insurance coverage on their parent’s plan (93%). Almost all participants reported initiating sexual
activity (97%) and half of participants (50%) reported currently being in a monogamous partnership.
Most participants reported using the oral contraceptive pill (62%) and/or the condom (52%) as a method
of contraception. There were no significant differences in the baseline characteristics of students in the
two groups. Retention rates at posttest were high, with no significant differences between conditions
(see Table 2).

Table 2. Baseline characteristics and retention rates.

Measure Total (n = 58) HPV (n = 29) Control (n = 29)

Age (SD), years 21.6 (2.2) 21.1 (0.8) 22.1 (2.9)
Sex, n (%)
Female 47 (81) 24 (85) 23 (79)
Male 11 (19) 5 (17) 6 (21)
Hispanic, n (%)
Yes 5 (9) 3 (10) 2 (7)
No 53 (91) 26 (90) 27 (93)
Race, n (%)
Caucasian 52 (90) 28 (97) 24 (83) *
African-American 3 (5) 1 (3) 2 (7)
Asian 2 (3) 0 (0) 2 (7)
American Indian/Native American 1 (2) 0 (0) 1 (3)
Academic year, n (%)
2nd year 1 (2) 0 (0) 1 (3)
3rd year 17 (29) 13 (45) 4 (14)
4th year 33 (57) 14 (48) 19 (66)
5th year 7 (12) 2 (7) 5 (17)
Vaccines 2020, 8, 749 7 of 15

Table 2. Cont.

Measure Total (n = 58) HPV (n = 29) Control (n = 29)

Health Insurance Status, n (%)
Parent’s Plan 54 (93) 28 (97) 26 (90)
None 3 (5) 1 (3) 2 (7)
Another plan 1 (2) 0 (0.0) 1 (3)
Age at first sexual intercourse (SD),
16.9 (1.6) 17.1 (1.8) 16.7 (1.3)
years
Number of sex partners (SD)
Past month 0.9 (0.6) 10 (0.6) 0.9 (0.6)
Past 6 months 1.9 (2.1) 1.7 (1.2) 2.1 (2.7)
Lifetime 7.0 (5.7) 6.6 (5.0) 7.5 (6.4)
Current monogamous partnership
Yes 28 (50) 14 (48) 14 (52)
No 26 (46) 14 (48) 12 (44)
Don’t Know 2 (4) 1 (3) 1 (4)
Retention rates 56 (97%) 29 (100%) 27 (93%)
* p value < 0.05.

3.2. HPV Vaccination Knowledge, Attitudes, and Behaviors

At baseline, the majority of participants in the HPV vaccination intervention group (n = 19;
66%) reported having received all three shots of the HPV vaccine series (see Table 3). At posttest,
two additional participants reported receiving all three shots of the HPV vaccine and an additional
three participants indicated that they planned to get vaccinated in the next 6 months. As a result,
at the conclusion of the intervention, 24 participants (83%) indicated that they had completed the HPV
vaccination or had a plan to receive the HPV vaccination in the next six months. Differences in HPV
vaccination between the intervention and control group were not significant, nor were there significant
differences in the change between groups at posttest (see Table 3).

Table 3. HPV vaccination status and intentions.

HPV (n = 29) Control (n = 29)

Pre Post Pre Post
Received full vaccination series (%) 19 (66) 21 (78) 14 (48) 15 (52)
Initiated partial vaccination series (%) 2 (7) 0 (0) 3 (10) 4 (14)
Never vaccinated (%) 7 (24) 3 (11) 9 (31) 8 (28)
Intend to get vaccinated within 6 months (%) 1 (3) 3 (11) 3 (10) 2 (7)
Fisher’s exact test was used to assess whether there were significant differences between and within groups at pre
and post. No significant differences were found.

At baseline, almost all participants knew that HPV can be spread through sexual intercourse
(97%). Fewer participants were aware that HPV can be spread through contact other than sexual
intercourse (64%). Approximately 91% of participants correctly responded that people who have been
infected with HPV might not have symptoms. While participants understood the link between HPV
and cervical cancer (93%), fewer participants knew that some types of HPV can cause anal cancer
(53%), oral cancer (57%), or genital warts (72%).
At posttest, knowledge of HPV and HPV vaccination improved among participants in the HPV
vaccination awareness intervention relative to those in the control condition (Table 4). Almost all
intervention participants reported that HPV can be spread through contact other than sexual intercourse
(93%). Participants understood that some types of HPV can cause oral cancer (100%), anal cancer (93%),
Vaccines 2020, 8, 749 8 of 15

and genital warts (100%). These improvements in knowledge were statistically significant compared
to the control group (see Table 4).

Table 4. HPV and HPV vaccination knowledge (%).

HPV Control
Difference in Change
Pre Post Pre Post
between Groups at
(n = 28) (n = 27) (n = 29) (n = 29)
Posttest (p-Value)
Some types of HPV can cause oral cancer.
65.5 100 * 48.3 69.0 0.007
Correct answer: True
Some types of HPV can cause anal cancer.
58.6 92.6 * 48.3 65.5 0.04
Correct answer: True
Some types of HPV can cause genital warts.
78.6 100 * 69.0 82.8 0.024
Correct answer: True
HPV can be spread through contact other
than sexual intercourse. 69.0 92.6 * 58.6 69.0 0.072
Correct answer: True
Condom use fully protects against the spread
of HPV. 69.0 92.6 75.9 82.8 0.42
Correct answer: False
HPV can cause an abnormal Pap (cervical
cancer screening) test. 82.8 96.3 82.8 86.2 0.186
Correct answer: True
People who have been infected with HPV
might not have symptoms. 86.2 100 96.6 96.6 0.33
Correct answer: True
HPV can be spread through sexual
intercourse. 100 100 93.1 100 1.00
Correct answer: True
Some types of HPV can cause cervical cancer.
96.6 100 89.7 93.1 0.165
Correct answer: True
An HPV infection can be cured.
27.6 37 65.5 41.4 0.049
Correct answer: False
Women who get the vaccine still need regular
Pap (cervical cancer screening) tests. 93.1 85.2 93.1 86.2 0.76
Correct answer: True
* p value < 0.05.

At pretest, approximately 35% of all participants reported that not being currently sexually active
influenced their intention to receive the HPV vaccination. At posttest, only 7% of the HPV vaccination
intervention group felt the same way, and the difference between the intervention and control group
from pretest to posttest was significant (p = 0.03).

3.3. Participants Reported Improvements in HPV Vaccination Knowledge, Attitudes, and Behaviors
Participants’ open-ended weekly reflections demonstrated an increase in knowledge about HPV
vaccination (see Table 5). According to one participant, “since the beginning of this intervention,
my knowledge of HPV drastically increased.” Participants believed that the intervention addressed
gaps in knowledge related to men’s susceptibility to HPV and the link between HPV and oral cancer.
Many students also reported that prior to the intervention they did not realize Student Health Services
provided the vaccine on campus. In addition to increasing knowledge, students reported that the
intervention changed their beliefs about HPV vaccination. Participants also described how increased
knowledge led to improved confidence and inspired conversations about HPV vaccination with family
and friends. According to one participant, “I now feel extremely confident in discussing all aspects of
HPV, including the importance of vaccination.”
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Table 5. Themes with illustrative quotes.

Table 5. Themes
Table 5. Themes with
with illustrative
illustrative quotes.
quotes.
Themes Illustrative Quotes
Themes “After reading all of the posts and Illustrative
doing some other Quotes
research I now believe that the vaccine is
Themes Illustrative Quotes
HPV vaccination “After reading all of the posts and doing
something everyone should have. I mean there is really some other research I now believe
no reason not to get thatvaccinated.”
the vaccine is
HPV vaccination
knowledge, “After
something
“My reading
viewpoint all of
everyone
has the postschanged
should
definitely and doing
have. for some
I mean there
the other research
is really
better. At I nownot
nobeginning
the reason believe getthat
oftothis theI vaccine
did not is
vaccinated.”
study,
knowledge, “My something everyone should have. Iformean there isAtreally no reason not to get vaccinated.”
attitudes, and
HPV vaccination know too terribly much about HPV. At this point I know quite a bit and I know the did
viewpoint has definitely changed the better. the beginning of this study, I factsnot
attitudes, and “My
know viewpoint
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definitely
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HPV. Atforthisthepoint
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know beginning
quite a bit andof Ithis
knowstudy,
the Ifacts
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knowledge,
behaviors attitudes, concerning the matter. I’ve been able to relay this information to my friends and family and help
know too terribly much about HPV. At this point I know quite a bit and I know the facts
behaviors
and behaviors concerning the them matter. I’vetake
even been ablein tothe
relay this information to my themselves.”
friends and family and help
concerning the matter. I’ve steps
been able toright
relaydirection to protect
this information to my friends and family and
“I believe thehelp them
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protect themselves.”
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direction towere
protect user friendly and easy to
themselves.”
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understand andmaterial
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not familiar week’s
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found it pretty and
easy easy
to useto
and follow along with.”
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“Many students even got to share personal and followstories along with.”who have had issues with HPV in the
ofalong
people
Intervention
engagement and use and follow with.”
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past. students even got to share personal stories of people who have had issues effected
with HPV in the
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engagement
treatment and “Many students even got to share personal stories ofpersonally
I believe this is important to share because if you people who knowhave someone
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serious HPV is.”

3.4. Intervention Engagement and Treatment Satisfaction

3.4. Intervention Engagement and Treatment Satisfaction Satisfaction
Electronic newsletters were opened each week by the majority of participants in the HPV
Electronic
Electronic
condition, newsletters
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Figure 1. Participant engagement with HPV vaccination awareness newsletters (n = 29). Note: No
Figure Participant
Figure 1.1. Participant engagement
engagement with with
HPV HPV vaccination
vaccination awareness
awareness newsletters
newsletters (n = 29). (n = 29).
Note: No
electronic newsletters were sent by the study investigators during spring break (Week 5).
Note: No electronic newsletters were sent by the study investigators during spring break
electronic newsletters were sent by the study investigators during spring break (Week 5). (Week 5).

Figure 2.
Figure Participant engagement
2. Participant engagement with
with HPV
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Participant engagement
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(Between group.
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Note: No Facebook posts were made by the study investigators during spring break (Between Weeks
Note:
and No
5). Facebook posts were made by the study investigators during spring break (Between Weeks
44 and 5).
4 and 5).
Vaccines 2020, 8, 749 10 of 15

Participants in the HPV vaccine awareness condition rated the intervention positively. Overall,
89% of participants indicated the intervention was helpful, 78% said that they would recommend it
to a friend, and 70% reported they enjoyed the program. Most participants (67%) reported that they
were satisfied with the number of lessons, the number of Facebook postings (56%), the length of the
Facebook postings (63%), and the extent of interaction with health educators on Facebook (81%).

3.5. Participants Reported High Intervention Engagement and Treatment Satisfaction

Based on the open-ended weekly reflections, Facebook emerged as an acceptable platform for the
intervention (see Table 5). Students appreciated the accessibility, flexibility, and ease of use of the social
media platform. According to one participant, “I liked the flexibility of using Facebook. It was easy to
log in and jump into the discussion whenever my schedule allowed it.” Even students who did not
previously have a Facebook account found the platform simple to use. Some participants believed that
the intervention became repetitive over time, especially on Facebook. Other participants described
“missing” posts on Facebook. According to one participant, “the Facebook content can be a little heavy;
since Facebook does not have the most simple [sic] layout, it is hard to make a post really stand out.”
Participants appreciated fun and interactive elements of the intervention, such as polls. Participants
also commented that Facebook encouraged interaction. According to one participant, “I really enjoyed
conversing and sharing opinions with peers via a social network. I felt more inclined to share more
personal information because it was online versus a face-to-face conversation.”
We also monitored level of engagement with the Facebook HPV intervention content (see Table 6).
These data were deidentified but monitored throughout the intervention period. One hundred percent
of HPV intervention participants participated in the private HPV Facebook group as part of the
HPV condition. Each week, an average of 23.9 participants (ranging from 16–28) actively engaged
in the group. Active engagement was measured by how many individuals commented, liked any
post, and liked comments that were made on posts. Level of engagement was stratified as the
following: high (21 or more) medium (11–20), and low (0–10). On average, there were 8.2 comments
(ranging from 0–24), 4.5 comment likes (ranging from 0–29), and 3.7 post likes (ranging from 0–13)
per week. On the individual level, each participant commented in the group an average of 2.4 times
per week (ranging from 0–9).

Table 6. Level of engagement with Facebook HPV intervention content.

Comments Post Likes Comment Likes

Level of Engagement
Number of Students Number of Students Number of Students
High (21+) 11 1 4
Medium (11–20) 12 6 5
Low (0–10) 6 22 20

4. Discussion
To our knowledge, this is the first study to deliver an HPV vaccination awareness intervention
through Facebook and electronic newsletters to college students. This technology-mediated,
theory-based HPV vaccination awareness intervention was well accepted by participants. Findings
suggest the approach was effective in improving knowledge about HPV and HPV vaccination.
Participants reported that the intervention addressed gaps in knowledge related to men’s susceptibility
to HPV and the link between HPV and oral cancer, which have been shown in previous studies to be
important gaps limiting HPV vaccination [53]. Participants also described how increased knowledge
led to improved confidence and inspired conversations about HPV vaccination with family and friends.
At the start of the 9-week study, approximately half of participants had previously received the full HPV
vaccination series (57%), which represents a considerably higher rate for full vaccination coverage than
might have been expected based on estimates for adolescents in South Carolina (43%) [8]. This may
reflect the high rates of insurance coverage in this sample since previous studies have indicated greater
Vaccines 2020, 8, 749 11 of 15

likelihood of completing the full HPV vaccination series among individuals with health insurance [54].
Despite the high levels of vaccination at baseline, almost half of the participants were inadequately
protected from HPV and associated HPV-cancers, with rates far below the Healthy People 2020 goal of
increasing HPV vaccination coverage to 80%.
At the conclusion of the HPV intervention, the number of participants initiating/completing
the vaccination series increased, as did the number of young adults indicating they intended to get
vaccinated in the next 6 months. The change in vaccination coverage was modest over this 9-week
period and did not differ statistically from the control group in this small feasibility study. However,
the demonstrated increase in knowledge about HPV and vaccination coupled with the suggestion of
a shift in intensions to get vaccinated suggests that the intervention offers a promising approach to
target the catch-up population and achieve the ambitious Healthy People 2020 80% full coverage goal.
Participants’ intervention engagement and treatment satisfaction suggest that this approach offers
utility and scalability among college students. The electronic newsletter showed high penetration with
approximately 90% of participants opening the email each week. Almost all participants interacted
on Facebook by “liking” a post or comment or posting a comment. An average of more than four
comments or likes were made per person each week throughout the intervention [55]. Participants
reported that Facebook was easy to use, accessible, and flexible, which likely contributed to the
success of the intervention. Students also described how an online social media platform encouraged
interaction and personal sharing, which reinforced intervention messages.

4.1. Implications for Practice

Although HPV vaccination is effective, low coverage remains a challenge for public health
professionals. College students represent an important catch-up population who are at increased risk
of acquiring HPV. This technology-mediated intervention supports research that social media serves as
an appropriate platform to improve awareness and vaccination coverage [22]. Intervention messages
and materials countered the dissemination of manipulative and false messages online in real-time,
providing a platform to address sensational and misleading coverage [23]. Findings support the
promise of eHealth by filling a gap in the evaluation of theory-based programs measuring engagement
in order to improve health behaviors and outcomes [56]. Specifically, this study evaluated objective
measures and qualitative in-depth reflections of engagement to show that the intervention resonated
with participants.

4.2. Study Limitations and Strengths

Findings should be understood within the context of the study’s limitations. The small sample
size and homogeneity of the population limit the generalizability of the results. The relatively short
intervention and lack of extended follow-up to confirm receipt of HPV vaccinations are limitations
of this study. Additionally, the relatively high baseline rate of full vaccination left modest room to
increase vaccination rates. Finally, there is a risk of contamination between conditions because students
were registered in two sections of the same course, with the same professor, at the same university and
both interventions were described in the informed consent document.
This pilot study offers a number of strengths that demonstrate potential for scalability and
dissemination of this intervention approach. In one of the first HPV vaccination awareness interventions
for college students delivered through electronic newsletters and Facebook, participants demonstrated
robust engagement and high treatment satisfaction. Moreover, the study was randomized and
controlled, with a high retention rate. Additional study strengths include the use of objective measures
and qualitative open-ended assessment of intervention engagement. Finally, the automated delivery
of electronic newsletters and Facebook posts represents an opportunity to replicate the intervention
with limited time and opportunity cost.
Vaccines 2020, 8, 749 12 of 15

5. Conclusions
A technology-mediated HPV vaccination awareness intervention increased college students’
knowledge of HPV and HPV vaccination. Objective measures and qualitative open-ended assessment
of the intervention showed high levels of engagement with the electronic newsletters and Facebook
group. The effectiveness of this pilot study suggests that social media is an appropriate platform to
reach college students with health promotion interventions and increase HPV vaccination awareness
in this important catch-up population.

Author Contributions: Conceptualization, H.M.B., B.S., G.T.-M., D.S.W.; Formal analysis, H.M.B. and B.S.;
Methodology, H.M.B., B.S., C.M.M., G.T.-M., D.S.W.; Writing—original draft, H.M.B. and B.S.; Writing—review
and editing, H.M.B., B.S., G.T.-M., C.L., M.S., K.M., A.G., D.S.W. All authors have read and agreed to the published
version of the manuscript.
Funding: This study was funded by internal funding from the University of South Carolina awarded to the
Technology Center to Promote Healthy Lifestyles within the Arnold School of Public Health at the University of
South Carolina. The funder had no role in the study conceptualization, design, execution, analysis, or interpretation
of results.
Acknowledgments: We thank the students who willingly participated in the pilot study.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to
publish the results.

References
1. Markowitz, L.E.; Dunne, E.F.; Saraiya, M.; Chesson, H.W.; Curtis, C.; Robinette, C.; Gee, J.; Bocchini, J.A., Jr.;
Unger, E.R.; Centers for Disease Control and Prevention (CDC). Human Papillomavirus Vaccination:
Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb. Mortal. Wkly. Rep.
2014, 63, 1–30.
2. Centers for Disease Control and Prevention. Young People Account for a Substantial Proportion of New
STIs. Division of STD Prevention: Atlanta, GA, USA, National Center for HIV/AIDS, Viral Hepatitis, STD,
and TB Prevention. 2015. Available online: https://www.cdc.gov/std/products/infographics.htm (accessed on
14 November 2020).
3. Centers for Disease Control and Prevention. The Link between HPV and Cancer; National Center for
Chronic Disease Prevention and Health Promotion: Atlanta, GA, USA, 2015. Available online: https:
//www.cdc.gov/hpv/parents/cancer.html (accessed on 14 November 2020).
4. Van Dyne, E.A.; Henley, S.J.; Saraiya, M.; Thomas, C.C.; Markowitz, L.E.; Benard, V.B. Trends in Human
Papillomavirus–Associated Cancers—United States, 1999–2015. Morb. Mortal. Wkly. Rep. 2018, 67, 918–924.
[CrossRef]
5. Food and Drug Administration (FDA). FDA Approves Gardasil 9 for Prevention of Certain Cancers Caused by
Five Additional Types of HPV; U.S. Department of Health and Human Services: Silver Spring, MD, USA, 2014.
Available online: http://www.fda.gov (accessed on 14 November 2020).
6. Markowitz, L.E.; Drolet, M.; Perez, N.; Jit, M.; Brisson, M. Human papillomavirus vaccine effectiveness
by number of doses: Systematic review of data from national immunization programs. Vaccine 2018, 36,
4806–4815. [CrossRef]
7. Spinner, C.; Ding, L.; Bernstein, D.I.; Brown, D.R.; Franco, E.L.; Covert, C.; Kahn, J. Human Papillomavirus
Vaccine Effectiveness and Herd Protection in Young Women. Pediatrics 2019, 143. [CrossRef] [PubMed]
8. Walker, T.Y. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents
Aged 13–17 Years—United States, 2017. Morb. Mortal. Wkly. Rep. 2018, 67. [CrossRef] [PubMed]
9. Barnard, M.; George, P.; Perryman, M.L.; Wolff, L.A. Human papillomavirus (HPV) vaccine knowledge,
attitudes, and uptake in college students: Implications from the Precaution Adoption Process Model.
PLoS ONE 2017, 12, e0182266. [CrossRef] [PubMed]
10. Brown, D.R.; Shew, M.L.; Qadadri, B.; Neptune, N.; Vargas, M.; Tu, W.; Juliar, B.E.; Breen, T.E.; Fortenberry, J.D.
A longitudinal study of genital human papillomavirus infection in a cohort of closely followed adolescent
women. J. Infect. Dis. 2005, 191, 182–192. [CrossRef]
Vaccines 2020, 8, 749 13 of 15

11. Baranowski, T.; Cullen, K.W.; Basen-Engquist, K.; Wetter, D.W.; Cummings, S.; Martineau, D.S.; Prokhorov, A.;
Chorley, J.; Beech, B.; Hergenroeder, A. Transitions out of High School: Time of Increased Cancer Risk?
Prev. Med. 1997, 26, 694–703. [CrossRef]
12. Gerend, M.A.; Shepherd, J.E. Predicting human papillomavirus vaccine uptake in young adult women:
Comparing the health belief model and theory of planned behavior. Ann. Behav. Med. Publ. Soc. Behav. Med.
2012, 44, 171–180. [CrossRef]
13. Gerend, M.A.; Shepherd, M.A.; Lustria, M.L.A.; Shepherd, J.E. Predictors of provider recommendation for
HPV vaccine among young adult men and women: Findings from a cross-sectional survey. Sex. Transm. Infect.
2016, 92, 104–107. [CrossRef]
14. Herrera-Ortiz, A.; Conde-Glez, C.J.; Olamendi-Portugal, M.L.; García-Cisneros, S.; Plett-Torres, T.;
Sánchez-Alemán, M.A. College women, HPV genotyping and sexual behavior before HPV vaccination:
Results from samples stored for a long time. J. Infect. Public Health 2018, 11, 286–289. [CrossRef] [PubMed]
15. Jones, S.G.; Mathis-Gamble, K.; Fenkl, E.A. Minority College Students’ HPV Knowledge, Awareness,
and Vaccination History. J. Assoc. Nurses. AIDS Care 2017, 28, 675–679. [CrossRef] [PubMed]
16. Kasymova, S.; Harrison, S.E.; Pascal, C. Knowledge and Awareness of Human Papillomavirus among College
Students in South Carolina. Infect Dis. 2019, 12, 1178633718825077. [CrossRef] [PubMed]
17. McCutcheon, T.; Schaar, G. HPV knowledge and vaccination rates in college-aged males: Implications for
practice. Nurse Pract. 2017, 42, 49–53. [CrossRef] [PubMed]
18. Smith, A.; Rainie, L.; Zickuhr, K. College Students and Technology. Pew Research Center. 2018.
Available online: http://www.pewinternet.org/2011/07/19/college-students-and-technology/ (accessed on
14 November 2020).
19. Pew Research Center. Internet/Broadband Fact Sheet. Washington, DC, USA, February 2018. Available online:
https://www.pewinternet.org/fact-sheet/internet-broadband/ (accessed on 14 November 2020).
20. Pew Research Center. Mobile Fact Sheet. Washington, DC, USA, February 2018. Available online:
https://www.pewinternet.org/fact-sheet/mobile/ (accessed on 14 November 2020).
21. Gramlich, J. 10 facts about Americans and Facebook. Pew Research Center. 2019. Available online:
https://www.pewresearch.org/fact-tank/2019/02/01/facts-about-americans-and-facebook/ (accessed on
14 November 2020).
22. Odone, A.; Ferrari, A.; Spagnoli, F.; Visciarelli, S.; Shefer, A.; Pasquarella, C.; Signorelli, C. Effectiveness of
interventions that apply new media to improve vaccine uptake and vaccine coverage A systematic review.
Hum. Vaccines Immunother. 2015, 11, 72–82. [CrossRef]
23. Briones, R.; Nan, X.; Madden, K.; Waks, L. When vaccines go viral: An analysis of HPV vaccine coverage on
YouTube. Health Commun. 2012, 27, 478–485. [CrossRef]
24. Zhou, X.; Coiera, E.; Tsafnat, G.; Arachi, D.; Ong, M.-S.; Dunn, A.G. Using social connection information
to improve opinion mining: Identifying negative sentiment about HPV vaccines on Twitter. Stud. Health
Technol. Inform. 2015, 216, 761–765.
25. Sundstrom, B.; Aylor, E.; Cartmell, K.B.; Brandt, H.M.; Bryant, D.C.; Hughes Halbert, C.; Young Pierce, J.
Beyond the birds and the bees: A qualitative content analysis of online HPV vaccination communication.
J. Commun. Healthc. 2018, 11, 205–214. [CrossRef]
26. Cates, J.R.; Shafer, A.; Diehl, S.J.; Deal, A.M. Evaluating a County-Sponsored Social Marketing Campaign
to Increase Mothers’ Initiation of HPV Vaccine for Their Preteen Daughters in a Primarily Rural Area.
Soc. Mark. Q. 2011, 17, 4–26. [CrossRef]
27. Cates, J.R.; Diehl, S.J.; Crandell, J.L.; Coyne-Beasley, T. Intervention effects from a social marketing campaign
to promote HPV vaccination in preteen boys. Vaccine 2014, 32, 4171–4178. [CrossRef]
28. Kennedy, A.; Sapsis, K.F.; Stokley, S.; Curtis, C.R.; Gust, D. Parental attitudes toward human papillomavirus
vaccination: Evaluation of an educational intervention, 2008. J. Health Commun. 2011, 16, 300–313. [CrossRef]
[PubMed]
29. Cohen, E.L.; Head, K.J.; McGladrey, M.J.; Hoover, A.G.; Vanderpool, R.C.; Bridger, C.; Carman, A.;
Crosby, R.A.; Darling, E.; Tucker-McLaughlin, M.; et al. Designing for Dissemination: Lessons in Message
Design from “1-2-3 Pap”. Health Commun. 2015, 30, 196–207. [CrossRef] [PubMed]
30. Cohen, E.L.; Head, K.J. Identifying knowledge-attitude-practice gaps to enhance HPV vaccine diffusion.
J. Health Commun. 2013, 18, 1221–1234. [CrossRef] [PubMed]
Vaccines 2020, 8, 749 14 of 15

31. Frank, L.B.; Murphy, S.T.; Chatterjee, J.S.; Moran, M.B.; Baezconde-Garbanati, L. Telling Stories, Saving Lives:
Creating Narrative Health Messages. Health Commun. 2015, 30, 154–163. [CrossRef]
32. Hopfer, S. Effects of a Narrative HPV Vaccination Intervention Aimed at Reaching College Women:
A Randomized Controlled Trial. Prev Sci. 2012, 13, 173–182. [CrossRef]
33. Krawczyk, A.; Lau, E.; Perez, S.; Delisle, V.; Amsel, R.; Rosberger, Z. How to inform: Comparing written and
video education interventions to increase human papillomavirus knowledge and vaccination intentions in
young adults. J. Am. Coll. Health 2012, 60, 316–322. [CrossRef]
34. Macario, E.; Matiella, A.C. A bilingual webnovela on the human papillomavirus: Will Latinas and health
professionals use it? J. Commun. Healthc. 2015, 8, 55–66. [CrossRef]
35. Sundstrom, B.; Carr, L.A.; DeMaria, A.L.; Korte, J.E.; Modesitt, S.C.; Pierce, J.Y. Protecting the Next Generation:
Elaborating the Health Belief Model to Increase HPV Vaccination among College-Age Women. Soc. Mark. Q
2015, 21, 173–188. [CrossRef]
36. Balatsoukas, P.; Kennedy, C.M.; Buchan, I.; Powell, J.; Ainsworth, J. The Role of Social Network Technologies in
Online Health Promotion: A Narrative Review of Theoretical and Empirical Factors Influencing Intervention
Effectiveness. J. Med. Internet Res. 2015, 17, e141. [CrossRef]
37. Betsch, C. Social media targeting of health messages. Hum. Vaccines Immunother. 2014, 10, 2636–2637.
[CrossRef]
38. Maher, C.A.; Lewis, L.K.; Ferrar, K.; Marshall, S.; De Bourdeaudhuij, I.; Vandelanotte, C. Are health behavior
change interventions that use online social networks effective? A systematic review. J. Med. Internet Res.
2014, 16, e40. [CrossRef] [PubMed]
39. Raviotta, J.M.; Nowalk, M.P.; Lin, C.J.; Huang, H.-H.; Zimmerman, R.K. Using FacebookTM to Recruit
College-Age Men for a Human Papillomavirus Vaccine Trial. Am. J. Mens Health 2016, 10, 110–119. [CrossRef]
[PubMed]
40. Zhang, N.; Tsark, J.; Campo, S.; Teti, M. Facebook for Health Promotion: Female College Students’ Perspectives
on Sharing HPV Vaccine Information through Facebook. Hawaii J. Med. Public Health 2015, 74, 136–140.
[PubMed]
41. Lai, C.-Y.; Wu, W.-W.; Tsai, S.-Y.; Cheng, S.-F.; Lin, K.-C.; Liang, S.-Y. The Effectiveness of a Facebook-Assisted
Teaching Method on Knowledge and Attitudes about Cervical Cancer Prevention and HPV Vaccination
Intention among Female Adolescent Students in Taiwan. Health Educ. Behav. 2015, 42, 352–360. [CrossRef]
[PubMed]
42. Sundstrom, B.; Brandt, H.M.; Gray, L.; Young Pierce, J. It’s My Time: Applying the health belief model to
prevent cervical cancer among college-age women. J. Commun. Manag. 2018, 22, 161–178. [CrossRef]
43. West, D.S.; Monroe, C.M.; Turner-McGrievy, G.; Sundstrom, B.; Larsen, C.; Magradey, K.; Wilcox, S.;
Brandt, H.M. A Technology-Mediated Behavioral Weight Gain Prevention Intervention for College Students:
Controlled, Quasi-Experimental Study. J. Med. Internet Res. 2016, 18. [CrossRef] [PubMed]
44. Rosenstock, I.M. The health belief model and preventive health behavior. Health Educ. Behav. 1974, 2, 354–386.
[CrossRef]
45. Rosenstock, I.M.; Strecher, V.J.; Becker, M.H. Social learning theory and the health belief model.
Health Educ. Behav. 1988, 15, 175–183. [CrossRef]
46. Prochaska, J.O.; Velicer, W.F. The Transtheoretical Model of Health Behavior Change. Am. J. Health Promot.
1997, 12, 38–48. [CrossRef]
47. Mills, L.A.; Head, K.J.; Vanderpool, R.C. HPV vaccination among young adult women: A perspective from
Appalachian Kentucky. Prev. Chronic Dis. 2013, 10. [CrossRef]
48. Hopfer, S.; Garcia, S.; Duong, H.T.; Russo, J.A.; Tanjasiri, S.P. A Narrative Engagement Framework to
Understand HPV Vaccination among Latina and Vietnamese Women in a Planned Parenthood Setting.
Health Educ. Behav. 2017, 44, 738–747. [CrossRef] [PubMed]
49. Bandura, A. Health promotion by social cognitive means. Health Educ. Behav. Off Publ. Soc. Public Health Educ.
2004, 31, 143–164. [CrossRef] [PubMed]
50. Group TDPP (DPP) R. The Diabetes Prevention Program (DPP): Description of lifestyle intervention.
Diabetes Care 2002, 25, 2165–2171.
51. Patel Divya, A.; Grunzweig, K.A.; Zochowski, M.K.; Dempsey, A.F.; Carlos, R.C.; Dalton, V.K.
Human Papillomavirus Vaccine Stages of Change among Male and Female University Students: Ready or
Not? J. Am. Coll. Health 2013, 61, 336–346. [CrossRef] [PubMed]
Vaccines 2020, 8, 749 15 of 15

52. Corbin, J.; Strauss, A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory,
3rd ed.; Sage Publications, Inc.: Thousand Oaks, CA, USA, 2008; 401p.
53. McBride, K.R.; Singh, S. Predictors of Adults’ Knowledge and Awareness of HPV, HPV-Associated Cancers,
and the HPV Vaccine: Implications for Health Education. Health Educ. Behav. 2018, 45, 68–76. [CrossRef]
[PubMed]
54. Kessels, S.J.M.; Marshall, H.S.; Watson, M.; Braunack-Mayer, A.J.; Reuzel, R.; Tooher, R.L. Factors associated
with HPV vaccine uptake in teenage girls: A systematic review. Vaccine 2012, 30, 3546–3556. [CrossRef]
55. Merchant, G.; Weibel, N.; Patrick, K.; Fowler, J.H.; Norman, G.J.; Gupta, A.; Servetas, C.; Calfas, K.; Raste, K.;
Pina, L.; et al. Click “Like” to Change Your Behavior: A Mixed Methods Study of College Students’ Exposure
to and Engagement With Facebook Content Designed for Weight Loss. J. Med. Internet Res. 2014, 16, e158.
[CrossRef]
56. Bull, S.; Ezeanochie, N. From Foucault to Freire through Facebook: Toward an Integrated Theory of mHealth.
Health Educ. Behav. 2015. [CrossRef]

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