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Vol.3, No.3, 301-309 (2013) Open Journal of Preventive Medicine
http://dx.doi.org/10.4236/ojpm.2013.33041
Disease prevention without relapse: Processes of
change for HPV vaccination
Anne C. Fernandez1,2*, Andrea L. Paiva1,2, Jessica M. Lipschitz1,2, H. Elsa Larson1,2,
Nicole R. Amoyal1,2, Cerissa L. Blaney1,2, Marie A. Sillice1,2, Colleen A. Redding1,2,
James O. Prochaska1,2
1Department of Psychology, University of Rhode Island, Kingston, USA; *Corresponding Author: annefernandez@gmail.com
2Cancer Prevention Research Center, University of Rhode Island, Kingston, USA
Received 8 April 2013; revised 12 May 2013; accepted 21 May 2013
Copyright © 2013 Anne C. Fernandez et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Human papillomavirus is the most
prevalent sexually transmitted infection in the
United States and is associated with 70% of
cervical cancers as well as over 90% of genital
warts. Although the HPV vaccine appears in the
US immunization schedule during adolescence,
a large percentage of women reach adulthood
without being vaccinated. The Transtheoretical
Model’s (TTM) Processes of Change (POC) con-
struct provides an assessment of participants’
experiences with HPV vaccination and is a cen-
tral component of computer-tailored interven-
tions designed to increase compliance with me-
dical recommendations, such as vaccination.
This study describes development and valida-
tion of a POC measure for increasing HPV vac-
cination among young adult women. Methods:
Cross-sectional measurement development was
conducted using an online survey to reach a
sample of 340 female college students repre-
senting vaccinated and unvaccinated women.
Factor analytic structural equation modeling as
well as evaluations of the stage by POC were
used to evaluate the validity of the POC measure.
Results: Confirmatory analyses supported the
theoretically expected ten-factor, fully correlated
model as the best fit for the data. Expected
Stage of Change to POC relationships were also
confirmed insofar as each POC was significantly
associated with Stage of Change, with the ex-
ception of dramatic relief. Follow-up analyses
suggested that individuals in the Precontempla-
tion stage used all POC less frequently than in-
dividuals in all other stages. Conclusions: The
POC measure was found to be internally and
externally valid in a sample of college-attending
women. The POC measure developed may be
used to tailor stage-matched interventions that
increase use of experiential and behavioral stra-
tegies important for increasing HPV vaccination
in this high-risk population.
Keywords: Human Papillomavirus;
Transtheoretical Model; Processes of Change;
Vaccine
1. INTRODUCTION
Human papillomavirus (HPV) is the most common
sexually transmitted infection in the United States [1].
High-risk types of HPV (specifically 16 and 18) are as-
sociated with 70% of cervical cancers diagnosed world-
wide and low risk-types of HPV, such as types 6 and 11,
are associated with 90% of genital warts cases [2]. It is
estimated that 80% of sexually active females will be
exposed to HPV before they reach 50 years of age [3].
Sexually active young women under 25 are at greatest
risk for HPV infection and US prevalence of HPV has
been shown to be highest among women aged 20 - 24
[4-6]. Female college students have been identified as a
high-risk population for HPV infection [7,8].
In June 2006, the Food and Drug Administration ap-
proved GARDASIL®, a highly efficacious quadrivalent
vaccine protective against HPV types 6, 11, 16, and 18
[9]. GARDASIL® is a three dose vaccine series adminis-
tered over six months. The American Committee on Im-
munization Practices has recommended routine vaccina-
tion of girls aged 11 - 12 and catches up vaccination of
females aged 13 - 26 [10]. Routine vaccination of girls
before sexual debut optimizes the protective benefit of
the vaccine, but vaccinating girls and women older than
Copyright © 2013 SciRes. OPEN ACCESS
A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309
302
12 years of age may also help to reduce cervical cancer
rates [11]. As of 2009, 44% of girls aged 13 - 17 reported
receiving at least one dose of the vaccine series and 27%
reported receipt of all three doses [12]. Data describing
vaccine uptake levels among women over 17 years of
age are limited, but the 2009 National Immunization Sur-
vey found 17% of women aged 19 - 26 had received at
least one dose of the HPV vaccine series [13]. Low vac-
cine uptake among college-aged females requires further
examination of variables that may influence vaccine
acquisition and completion.
One behavior change model particularly well-suited to
examining motivation and decision-making related to
HPV vaccination is the Transtheoretical Model of Change
(TTM). The TTM is an integrative model of behavior
change that has been applied to over 48 health behaviors
[14]. It is organized around the Stages of Change and
uses ten Processes of Change (POC) to represent activi-
ties and experiences that are applied when engaging in
intentional behavior change [15,16]. Stage of Change is
comprised of five stages: Precontemplation (not intend-
ing to change), Contemplation (considering change), and
Preparation (preparing to make a change), Action (ac-
tively engaged in behavior change), and Maintenance
(sustaining change). Additional TTM constructs include
Decisional Balance and Self-efficacy. Decisional Balance
reflects the individual’s weighing of the pros and cons of
changing their behavior [17]. Self-efficacy describes the
individual’s situation specific confidence that they can
sustain their behavior change despite high-risk or tempt-
ing situations to relapse to their unhealthy behavior [18-
20].
The POC represent the functional dimension of the
TTM, outlining the experiential and behavioral ways in
which people change [16,21,22]. There are ten POC,
comprised of covert and overt activities representing two
broad correlated experiential and behavioral domains.
The experiential POC represent more covert cognitive
and affective experiences/activities, and the behavioral
POC represent more overt strategies, like substituting
healthy alternatives, finding social support, and re-
organizing the environment to promote behavior change
(see Table 1). Unlike Decisional Balance which shows a
high level of consistency across Stage of Change for 48
health behaviors [14], the pattern of POC across be-
haviors is less clear. In a comparison of 34 studies on
smoking cessation, exercise, substance abuse, diet, and
psychological problems, Rosen [23] found varying pat-
terns of experiential and behavioral POC across health
behaviors, but did not integrate the pattern of POC across
all behaviors the way Hall and Rossi [14] did for the
patterns of Decisional Balange across Stage of Change.
Thus the consistency of POC across health behaviors
remains unknown and it is important to conduct model
Table 1. Processes of change.
Process Name Description Mean SD
Experiential Processes
Consciousness
Raising
Efforts by the individual to
gain awareness, gather
information, or get feedback
regarding the target behavior.
11.31 3.74
Dramatic
Relief
Expression and experience of
affect related to the target
behavior (e.g. fear, hope,
empowerment).
12.31 4.40
Environmental
Reevaluation
Consideration of how the
target behavior influences the
physical and social
environment.
11.48 4.85
Self
Reevaluation
Cognitive and emotional
reappraisal of one’s values
related to the target behavior.
12.36 4.50
Social
Liberation
Considering the social
climate and norms related to
the target behavior.
12.58 4.15
Behavioral Processes
Counter
Conditioning
Applying new ways of
thinking and behaving to
promote behavior change.
10.34 4.51
Stimulus
Control
Strategic control of
situations/triggers that may
interfere with or promote
behavior change.
9.32 4.32
Self
Liberation
Commitment to change and
belief in one’s ability to
change.
12.5 4.32
Reinforcement
Management
Application of behavioral
contingencies to promote
behavior change.
10.85 4.45
Helping
Relationships
Use and availability of other
people for social and
emotional support while
making a behavioral change.
12.27 4.55
testing when applying the TTM to new behaviors.
HPV vaccination is unique relative to other health be-
haviors because it lacks a traditional behavioral Main-
tenance stage and requires relatively little overt beha-
vioral effort to reach the Action stage. Maintenance for
HPV vaccination is effectively under biological control
once the final dose of the vaccine is completed. People
who achieve full-vaccination are no longer dependent on
POC or relapse-prevention strategies that typically cha-
racterize the Maintenance stage. For most behaviors
(such as smoking) the decision to act (i.e. quit) can sig-
nificantly increase the need for behavior controls to keep
progressing and prevent relapse. However, one cannot
relapse from vaccination, and thus the Action and Main-
tenance stages are combined for this application of the
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A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309 303
TTM to HPV vaccination. This staging modification has
been successfully applied in organ donation research in
the past [24,25], but this is the first published application
of the Processes of Change to a behavior without a
Maintenance stage.
The aim of the current research was to conduct model
testing for the TTM POC measure specific to HPV vac-
cination among young adult women. This research also
serves as an important part of the foundation for a future
theory-based intervention.
This project is part of a larger program of research that
has already developed measures for Stages of Change,
Decisional Balance, Self-efficacy, and knowledge related
to HPV and HPV vaccination. This study extends this
current program of research on HPV vaccination among
adult women by 1) developing a POC measure specific
to HPV vaccination in young adult women; 2) conduct-
ing tests of external validation by examining patterns of
POC across Stage of Change; and 3) and examining the
relationships between the POC measure and other im-
portant TTM constructs.
2. METHODS
2.1. Participants
A sample of 340 female college students (aged 18 to
26) representing a range of HPV vaccination experiences
were recruited in the spring and summer of the recruit-
ment year. The modal age of participants was 18 and the
median was 19. The sample was primarily white (76%).
The mean GPA was 3.01 (SD = 0.52) and the majority of
participants lived on campus (64%). The majority of par-
ticipants (93%) reported having health insurance. Among
these individuals, just over half (59%) indicated that the
HPV vaccine was covered by their insurance company,
2% indicated it was not, and 39% indicated that they “did
not know.” About half of the sample (50.3%) had re-
ceived the full HPV vaccine series and were categorized
in to the Action/Maintenance Stage. An additional 7.1%
were in the Preparation stage, 11.2% were in the Con-
templation stage, and 31.5% were in the Precontempla-
tion stage.
All participants were recruited through undergraduate
introductory psychology courses, and e-mail list-serves
at a mid-sized public university in the northeastern
United States. Participants in earlier Stages of Change
(pre-Action) were oversampled in order to procure an
adequate number of participants in each Stage of Change.
Participants were compensated with either class credit or
a $20 gift card to a local business. Surveys were admin-
istered online and accessed through a secure website sent
to students by e-mail and/or psychology course websites.
Participants were required to read the consent form and
indicate agreement prior to accessing the survey. Human
subject’s procedures were approved by the university’s
institutional review board.
2.2. Measurement Development Overview
A three stage process of measurement development
was used [26,27]. This procedure included item devel-
opment and refinement using focus groups and expert
reviews followed by structural equation modeling analy-
ses to refine the POC scales and external validation with
existing TTM measures [26-28]. As this was an effort to
build a POC model for HPV vaccination, Confirmatory
Factor Analysis (CFA) using Structural Equation Mod-
eling (SEM) was used as the primary model development
analysis. SEM requires that the conceptualizations of a
theory’s constructs be especially strong, with clearly de-
fined and testable hypotheses as to how the constructs
relate to one another. The POC model has been tested
numerous times with other health behaviors [22,29-31].
The testing of various models against one another is an
additional asset of CFA that is rarely practiced with other
statistical techniques, and can further the understanding
of how well a data set supports theoretical hypotheses.
Ultimately, the retained model should be the one that fits
the data best, both conceptually and empirically [28].
Initial Item Development and Refinement
Initial item development and refinement was based on
a review of the literature supplemented with expert con-
sultation, focus groups and cognitive interviews and fol-
lowed by pilot testing. Three 1.5-hour focus groups were
conducted (N = 11). The primary purpose of these
groups was to assess the HPV-related belief and attitudes
of students and generate additional item content that may
have been lacking in the literature. Once the items were
finalized, five one-on-one cognitive interviews were con-
ducted. The primary purpose of these interviews was to
determine clarity and readability of the item pool and the
instructions sets within the survey. All participants were
undergraduate women ages 18 to 26 years old.
2.3. Measures
2.3.1. Stage of Change
A short series of questions regarding past and present
experience with the HPV vaccination was administered
[32]. These questions were designed to place participants
in one of four mutually exclusive categories for Stage of
Change (Precontemplation, Contemplation, Preparation,
and Action/Maintenance). Participants who reported fin-
ishing the 3-shot vaccine series were categorized in the
Action/Maintenance stage. Participants who were plan-
ning to start the vaccination series within the next 30
days (or complete within the next 6 months) were cate-
gorized in the Preparation stage. Individuals who planned
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A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309
304
on starting the vaccination within the next six months
were categorized in the Contemplation stage, and those
who had no intention of starting or finishing the vaccine
series were classified in the Precontemplation stage. In-
dividuals in the Precontemplation stage were asked an
open-ended follow-up question regarding why they did
not plan to start or complete the HPV vaccine series.
Individuals in the Action/Maintenance stage were asked
who recommended the HPV vaccine. Response options
included Mother, Father, Yourself, Healthcare Provider/
Doctor, Other (Open-Ended).
2.3.2. Decisional Balance
The Decisional Balance scale consists of eight items,
four to represent the pros (e.g., protecting myself from
HPV would make me feel good) and four items to repre-
sent the cons (e.g., it would be embarrassing to talk to
my parents or doctor about getting vaccinated) of getting
the HPV vaccine. Participants were asked to rate how
important each item is in their decision of whether to get
the vaccine. Response options were on a 5-point scale
ranging from 1 “Not important at all” to 5 “Extremely
important”.
2.3.3. Self-Efficacy
The Self-efficacy scale consists of six items aimed at
measuring participants’ confidence in their ability to get
the vaccine in situations that may prove challenging (e.g.,
when it is inconvenient). Responses were made on a
5-point scale, ranging from 1 “Not at all confident” to 5
“Extremely confident”.
2.4. Analysis
An iterative set of analyses was conducted utilizing
structural equation measurement modeling. The aims of
these analyses were to: 1) provide estimates of the factor
loadings and 2) estimate internal consistency for each
component using Cronbach’s alpha. Item selection was
an iterative process, in which items with poor loadings
(<0.40) were removed, and analyses were repeated. Final
item selection was also determined on the basis of item
clarity, lack of redundancy, and conceptual breadth.
Once the final items were chosen, multiple measurement
models were compared also using structural equation
modeling.
In order to determine the model of best fit, four fit in-
dices were used: the likelihood ratio chi-square statistic,
goodness of fit index (GFI), the comparative fit index
(CFI), and the average absolute standardized residual
statistic (AASR). Traditionally, values of 0.80 - 0.89 on
the GFI and CFI indicate adequate to marginal fit, while
values of 0.90 and above indicate good to excellent fit.
For the AASR, values below 0.06 indicate excellent fit.
More conservative criteria state that an acceptable GFI
and CFI should be at least 0.90 while 0.95 and above
indicate excellent fit. Factor loadings were assessed and
retained above the adequate value of 0.40.
The TTM hypothesizes that individuals in different
Stages of Change will differ significantly on their scores
for the Processes of Change subscales [22]. Multivariate
Analysis of Variance (MANOVA) tests were conducted
on all POC variables by Stage of Change. In order to fa-
cilitate comparison in the magnitude of differences in
scale scores among the different subscales and between
the results of this study and previous studies examining
TTM scales, raw scores were converted to T-scores
(Mean = 50, standard deviation [SD] = 10). Correlations
were examined to determine the relationship between
each POC subscale and other TTM variables, including
pros, cons, and Self-efficacy.
3. RESULTS
3.1. Initial Item Development and
Refinement
Literature reviews and focus groups were successful in
conceptualizing and developing a total of 77 items re-
flecting the 10 POC as they related to HPV vaccination
among women. Items were further refined and clarified
during cognitive interviews with participants.
3.2. Descriptive Data
Descriptive data gathered with reference to additional
motivational influences related to HPV vaccination re-
vealed that among those who were vaccinated (in the
Action/Maintenance Stage) 63% reported that the vac-
cine was recommended to them by a doctor or other
health care provider, 28% by their mother, 6% self-
recommended, 1% by their father, and <1% by their high
school or college. Participants who were not intending to
start or finish the vaccine in the next six months gave a
variety of reasons as to why they were not planning on
receiving the vaccine. The largest proportion of students
indicated fear of risks or side effects (24%). Many indi-
viduals (14.6%) felt they did not have adequate knowl-
edge or were undecided about vaccination Additional
reasons included a lack of perceived need or personal
risk (14.6%), lack of time/motivation (11.5%), believing
that the vaccine was too new and insufficient research
had been conducted (11.5%), moral/personal reasons
(8.3%), being told not to get the shot by a parent or doc-
tor (6.3%), logistical barriers such as cost/access (5.2%),
and fear of shots (3.1%).
Measure Development
Seventy-seven items were included in the confirma-
tory structural equation modeling analysis for this meas-
ure. Diagnostic indicators provided by the analysis were
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A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309 305
used to detect poorly functioning items. Four items with
low loadings (<0.40) on their respective factors were
deleted. With these items removed the modeling was re-
peated and further item deletions were made based on
item loading, item complexity, and breadth of construct.
These procedures ultimately reduced the number of items
from 77 to 40 (4 items per process). Scale means and
standard deviations can be seen in Table 1.
Two models were tested: 1) null model (suggesting no
latent factors and used as a comparative model) and 2)
ten correlated factor model. The ten-factor correlated
model demonstrated the best fit to the data,
2 (695) =
2185.48, p < 0.001; CFI = 0.87, GFI = 0.74 and AASR =
0.043. Standardized factor loadings for each item are
displayed in Figure 1. The internal consistencies were
good, with Cronbach’s alphas ranging from 0.76 to 0.92.
3.3. External Validation
The results of the MANOVA examining scores on the
ten POC across the Stages of Change were F (30,960) =
4.72, p < 0.001, η2 = 0.13. Follow-up ANOVAs revealed
that each of the POC subscales was significantly associ-
ated with Stages of Change (p value’s < 0.001), with the
exception of Dramatic Relief (p = 0.09). Inspection of
the POC means across Stage of Change using follow-up
Tukey tests revealed that individuals in the Precontem-
plation stage used all POC less than individuals in all
other stages (p value’s < 0.05) (see Figures 2 and 3).
Effect sizes computed for change in POC from Precon-
templation to Contemplation ranged from d = 0.38 to d =
0.75. These are medium to large in magnitude [33].
Mean differences across the later Stages of Change
(e.g. Contemplation to Preparation) were not significant.
Despite null findings, effects sizes observed for change
in Social Liberation (d = 0.31) and Stimulus Control (d =
0.30) from Contemplation to Preparation, do not rule out
the possibility of clinically meaningful change.
The correlations among the POC subscales (experien-
tial and behavioral), Decisional Balance, and Self-effi-
cacy were examined. As can be seen in Table 2, the ex-
periential and behavioral POC were strongly positively
correlated with one another and moderately correlated
Table 2. Correlations between processes of change and other
TTM constructs.
Behavioral
Processes Pros Cons Self-Efficacy
Experiential Processes 0.903** 0.467** 0.064 0.253**
Behavioral Processes -- 0.398** 0.044 0.279**
Pros -- 0.016 0.276**
Cons -- −0.022
Self-Efficacy --
**p < 0.01 level (2-tailed).
with Pros and Self-efficacy. Cons of seeking the vaccine
were not correlated any of the other constructs for HPV
vaccination.
4. DISCUSSION
The primary objective of this study was to develop a
reliable and valid measure of the Processes of Change
applied to HPV vaccination among young, adult, col-
lege-attending women. Results indicate that the POC
measure is reliable and has a stable factor structure. The
hypothesized correlated ten-factor structure was sup-
ported.
Similar to previous TTM research, our findings indi-
cate that the POC were used least by individuals in the
Precontemplation stage. This is consistent with past re-
search and theory [34] indicating that Precontemplators
traditionally score lowest on the majority of POC be-
cause they are least ready to change their thoughts and
actions regarding a given behavior [19,21]. The steepest
increase in use of all POC occurred between the Precon-
templation and Contemplation stages. The observed ef-
fect sizes for these increases were medium to large in
magnitude. These findings coincide with research indi-
cating that across health behaviors a large proportion of
between stage variance is accounted for by the difference
between Precontemplation and all other stages combined
(typically, 70% for experiential POC and 50% for be-
havioral POC) [23]. The early and parallel increase in
experiential and behavioral POC suggests that for HPV
vaccination cognitive and affective experiences coincide
with strategic use of personal, social, and environmental
resources to promote behavior change.
Clinically, this research can be used to help develop
TTM tailored interventions by identifying POC that are
emphasized the most or least at particular Stages of
Change. While the patterns did not reach statistical sig-
nificance, Dramatic Relief, was the process emphasized
most in Precontemplation but the least in Action/Main-
tenance. Self-reevaluation, was emphasized the least in
Precontemplation but the most in Preparation. In terms of
behavioral POC, Stimulus Control and Reinforcement
Management, were emphasized least in Precontempla-
tion but most in Action/Maintenance indicating the need
for women in later stages to receive feedback on how to
manage stimuli and environmental contingences to com-
plete the vaccine series. Additional research using a lar-
ger sample is needed to confirm these findings.
This study also reported correlations between POC
and other TTM constructs for which relevant published
comparisons are unavailable. Our findings indicated that
the experiential and behavioral POC were positively
correlated with pros and Self-efficacy. These positive
correlations are consistent with TTM theory, which in-
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A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309
Copyright © 2013 SciRes.
306
Figure 1. HPV vaccine acquisition processes of change structural mode. CR = Consciousness Raising, DR = Dramatic Relief, ER =
Environmental Reevaluation, SR = Self Reevaluation, SO = Social Liberation, CC = Counter Conditioning, SC = Stimulus Control,
HR = Helping Relationships, RM = Reinforcement Management, SL = Self Liberation.
dicates that a greater number and/or broader range of
experiential and behavioral mechanisms are utilized by
individuals in later Stages of Change when pros and Self-
efficacy are also increasing.
OPEN ACCESS
A. C. Fernandez et al. / Open Journal of Preventive Medicine 3 (2013) 301-309 307
Figure 2. Experiential processes of change X stage of change.
Figure 3. Behavioral processes of change X stage of change.
PC = Precontemplation, C = Contemplation, PR = Preparation,
A/M = Action/Maintenance CR = Consciousness Raising, DR
= Dramatic Relief, ER = Environmental Reeavaluation, SR =
Self Reevaluation, SO = Social Liberation, CC = Counter Con-
ditioning, SC = Stimulus Control, HR = Helping Relation-
ships, RM = Reinforcement Mangagement, SL = Self Liber-
ation.
Based on these correlations, the experiential POC ac-
counted for 21.8% of variance in pros but less than 7%
of Self-efficacy. This finding indicates the decision to
receive the HPV vaccination may emphasize cognitive
processes and perceived advantages of vaccination, ra-
ther than confidence in one’s ability to carry out a be-
havior. The finding that POC is related to pros but not
cons suggests that future interventions’ emphasis should
perhaps be placed on the POC that have the highest cor-
relations with the Pros.
Limitations of this study include the use of a single
sample of predominantly white college students residing
in the Northeastern United States. Although results of the
current research indicate adequate scale reliability and
factor stability, further validation is needed among a
more diverse sample of young adult women in terms of
geography, education, race, and ethnicity. Replication of
these findings across diverse samples will provide further
evidence of internal and external validity.
Our findings underscore the need for HPV vaccination
interventions for women in the earliest Stages of Change
when POC need to increase the most. Over 63% of un-
vaccinated women in this study were in Precontempla-
tion Stage, and 9 out of 10 POC increased significantly
between Precontemplation and Contemplation. TTM-
tailored interventions should focus on increasing the use
of all POC among individuals in the Precontemplation
Stage, and maintaining the use of POC until vaccination
is complete. This can be done strategically through inter-
ventions that use tailoring to accelerate an individual’s
progress through the Stages of Change [35]. The POC
measure validated in this study offers 40 items that could
provide innovative behavioral and experiential tactics for
producing behavior change. Another direction for inter-
vention efforts is to utilize health care providers or clin-
ics to deliver change-related messages. In this study the
most common source cited for vaccination recommenda-
tion was health care providers. The most common reason
not to get vaccinated was fear of vaccine-related risks
and side-effects.
The current research in combination with several other
published reports on TTM measurement development for
HPV vaccination [32,36] can provide a foundation for
developing a TTM-tailored intervention to increase HPV
vaccination among young adult women. Due to low rates
of vaccination among this population, the need for em-
pirically-based, easily disseminated interventions is clear.
The current study represents a first step in developing
such an intervention and provides initial guidelines for
applying POC across Stage of Change.
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