Skip to main content
Download PDF
Download ePub

Designing and psychometric assessment of the scale of factors influencing HPV vaccine uptake behaviors in young adults

Infectious Agents and Cancer volume 17, Article number: 48 (2022) Cite this article

Abstract

Background

In order to increase HPV vaccination, it is necessary to identify the factors influencing vaccination behavior among different cultures and the young adult populations. To evaluate the factors influencing HPV vaccine uptake behaviors, valid, reliable, and culture-compatible scales are required. This study was conducted with the aim of designing and psychometric assessment of the scale of factors influencing HPV vaccine uptake behaviors in Young Adults (FI(HPV)VUBYA) in Iran.

Methods

The present study was carried out in a mixed-method in two steps: (a) Generating items using a qualitative study and literature review and (b) Reducing items by psychometric assessment of the designed scale. The initial set of items (N = 80) was prepared based on a qualitative study and literature review. A total of 400 young adults participated in online data collection from November 2019 to February 2020. The validity (face, content, and construct) and reliability (internal consistency and stability) of the scale were evaluated.

Results

The exploratory factor analysis (EFA) revealed that the scale has 7 factors, explaining 57.84% of the total extracted variance. There was also a knowledge factor that EFA did not analyze, but its validity and reliability were evaluated with 7 other factors. The results of confirmatory factor analysis showed a good model fit. Convergent and divergent validity of the scale was accepted for all factors. Good reliability was also reported for the scale.

Conclusion

FI(HPV)VUBYA 8-factor scale has good validity and reliability among young Iranian adults. Due to its appropriate psychometric properties, this scale can be used on this population in future studies.

Background

Cervical cancer is a serious public health problem and the fourth leading cause of death in women due to cancer, with a mortality rate of 7.5% [1, 2]. Approximately, 270,000 deaths from cervical cancer occurred in 2015 in low- and middle-income countries, which was 18 times more than in developed countries [3]. There is a relationship between the incidence of cervical cancer and infection with the human papillomavirus (HPV) [4]. HPV is one of the most common sexually transmitted diseases [5]. Persistent infections with high-risk types of HPV, especially strains 16 and 18, are involved in 20% and 50% of cervical cancer, respectively [6].

The HPV vaccine is an effective way to reduce the risk of HPV transmission in both men and women [7]. In the review of the safety of the HPV vaccine, the Centers for Disease Control and Prevention reported no difference in side effects between vaccinated and unvaccinated individuals [8]. In 2006, the HPV vaccine was approved by the US Food and Drug Administration for adolescent girls [9] and in 2011, the HPV 9-valent vaccine for boys [10]. However, HPV vaccines are less common in developing countries [11, 12]. For instance, HPV vaccinations among Vietnamese youth (5.7%) were significantly lower than their American peers (42%) [13]. In a study by Dadashi et al. in Iran, the prevalence of HPV infections (38.6%) was reported in women with cervical cancer [14]. The estimated cost of HPV vaccination in Iran was economically viable [15]. The HPV-related vaccines are rare in Iran and we do not have statistics on the rate of HPV vaccination.

Significant demographic and social changes have taken place worldwide [16], including increasing the age of marriage, increasing the educated people, and changing the family structure [17]. As a result, premarital sex has gradually become very common among young people in the world [18]. In young adults aged 15–24 years, unsafe sex plays an important role in the disability-adjusted life years [19]. Focusing on this age group is important because young adults are at higher risk for HPV infection [20].

Despite global changes in the liberalization in attitudes toward premarital sex and the effects of the media and globalization, Iranian youth face significant paradoxes due to the cultural and Islamic background of society. In addition, current Iranian society faces disagreements about sexual attitudes [21]. As a result, sexual issues are not as openly expressed or discussed as in Western countries [22]. Given that 48% of the Iranian population is between the ages of 15 and 24 years [23], this can increase sexually transmitted diseases among young adults in Iran.

Despite the importance of studying the FI(HPV)VUBYA, quantitative and qualitative studies have identified these factors. They include lack of information about the vaccine, its side effects, lack of advice from healthcare providers about the vaccine, vaccine costs, norms and social values related to sexual activity, and lack of trust in vaccination programs and healthcare providers [24,25,26,27]. In Iran, there is no study examining FI(HPV)VUBYA based on a qualitative study, and there are only limited cross-sectional studies on the attitudes and knowledge of women, parents, youth, and healthcare providers about HPV and related vaccines. In these studies, it has been reported that people did not get the vaccine due to lack of knowledge about HPV and related vaccines [28,29,30]. One of the biggest concerns about the HPV vaccine has been reported its side effects and its costs, respectively [31].

Questionnaires were designed to inform parents and specialists about the HPV vaccine. A questionnaire was designed in Malaysia to assess the knowledge, attitude, and practice of adults about HPV vaccination from the perspective of healthcare providers [32]. A questionnaire was also designed to increase the HPV vaccine completion in young adults by surveying students about the HPV [33]. Another questionnaire was designed in France to determine the doubt about HPV vaccination among mothers [34]. A questionnaire was also designed to determine the intention of getting vaccines for six diseases (measles, pertussis, pneumococcal infection, influenza, tetanus, and HPV) from the perspective of specialists [35]. Another questionnaire was designed in Israel to assess the knowledge, attitude, and practice of HPV vaccination from the perspective of physicians [36]. Most of the designed questionnaires examined the viewpoints of mothers and experts about vaccination or completing their vaccination period in young people, and also obtained the items of the questionnaire from the literature review. No study or limited studies were found examining the FI(HPV)VUBYA questionnaire from a young adult’s perspective and used a qualitative study to design items.

Regardless of the quality of the questionnaires, differences in the target population and the lack of a complete and valid questionnaire examining all aspects of FI(HPV)VUBYA was the reason for not using these questionnaires in the study population. Given the importance of FI(HPV)VUBYA as an indicator to improve vaccination and the need to pay more attention to these factors for young adults, this study aims to identify FI(HPV)VUBYA and then design a valid scale to accurately measure these factors. The FI(HPV)VUBYA results will have benefits for both young adults and the health system. This helps identify barriers to vaccination from a variety of perspectives, and the health system addresses them with the help of universities, schools, and health centers.

Designing

This exploratory sequential mixed—method study was conducted from May 2019 to March 2020 among young Iranian adults aged 18–26 years. It consisted of two steps, including (1) Generating items based on a qualitative study and literature review to form FI(HPV)VUBYA and (2) Reducing items by conducting a cross-sectional study for psychometric assessment of items obtained in the first step (Fig. 1).

Fig. 1
figure 1

Flow chart of two phases of study

Full size image

Methods

Step 1: generating items

Qualitative study

An in-depth understanding of the concept was achieved using conventional content analysis and face-to-face, in-depth, and semi-structured interviews from May to September 2019. Thirty participants (10 young adults and 20 specialists) were invited for interviews. Participants were sampled purposefully with maximum variance (age, sex, marital status, education, occupation, and work experience). Interview questions were designed and two interviews were conducted as a pilot and minor changes were made to the questions. Interviews were then conducted by one of the authors (the duration of each interview was 30–60 min) and each interview was transcribed. The transcripts of the interviews were analyzed using MAXQDA10 software and Graneheim and Lundman method. Similar codes were placed in sub-categories and related sub-categories were placed in categories and named. Lincoln and Guba's criteria were used to ensure the reliability of quality data, which included credibility, dependability, confirmability, and transferability [37].

Literature review

In this study, by reviewing the existing texts and literature using keywords “Human Papillomavirus Vaccine, Effective Factors or Determinant, Barriers, Motivation, Facilitators, Young adults” in the databases “Science Direct, Pub Med, ProQuest, Scopus” and Persian databases, related articles from 2000 to 2019 were reviewed. Availability of the full text of the article in Persian and English was the inclusion criterion. In the initial search, 500 articles (480 English and 20 Persian languages) and 10 dissertations were obtained. After removing duplicates and irrelevant studies, 30 articles (20 English and 10 Persian languages) and 3 dissertations remained. Primary codes FI(HPV)VUBYA were extracted from them.

Preparing the scale

Finally, FI(HPV)VUBYA were determined by using the codes extracted from the qualitative findings section and literature review. Based on the extracted codes, the appropriate expressions were placed in each categories and the total number of items was 130. In repeated sessions of the research team, writing, grammar, and similarities were examined, and some items were merged and deleted. Thus, the number of items was reduced from 130 to 90 items and to 80 items after re-examination. Finally, FI(HPV)VUBYAS with 80 items was prepared for psychometric assessment.

Step 2: reducing items

Features of FI(HPV)VUBYAS for knowledge items with a 3-point Likert scale (yes, no, and I do not know) and for the rest of the items (attitude) with a 5-point Likert scale (strongly agree to strongly disagree) in terms of face validity, content, construct, and reliability were evaluated.

Face validity

Qualitative and quantitative face validity was used for FI(HPV)VUBYAS. Ten young adults evaluated the items. They were first asked to rate the scale based on the difficulty or ambiguity of the items. According to the participants, the necessary modification was made for some items. In quantitative face validity, the impact score of the items was calculated. The 10 young adults were asked to choose one of the following five answers for each items: “extremely important, important, average importance, of little importance, and not important at all” scores were determined based on the Likert scale (1–5 scores). Score 1 indicated the not important at all and score 5 indicated the extremely important. Using the (Impact Score = Frequency (%) × Importance) formula, items with an impact factor score greater than 1.5 were acceptable [38]. Fourteen items on the scale received an impact score of less than 1.5, which were removed according to the research team's opinion. The scale entered the content validity step with 66 items.

Content validity

In qualitative content validity, 10 specialists in health education, reproductive health, psychologist, and social physician were used to review the items based on grammar, writing, and proper placement of items as well as appropriate scoring. According to their feedback, 10 items were removed and 2 items were added. Then, 58 items entered the quantitative content validity step. The content validity ratio (CVR) was examined to assess the necessity of the items (essential 3, useful but not essential 2, and not necessary 1). Given that the number of specialists was 10, the minimum acceptable CVR score based on Lawshe was considered to be 0.62 [39]. At this step, 4 items were removed (CVR < 0.62). Eventually, the items were reduced from 58 to 54. The Content Validity Index (CVI) showed how relevant each item is to the 4-point Likert scale (related 4, relevant but need minor revision 3, somewhat related but needs to be revised 2, and unrelated 1) conducted by 10 other specialists. All items were above 0.79. To eliminate the odds ratio, Kappa was calculated for each item (good = 0.60–0.74 and excellent value of Kappa > 0.74) [40]. All items had acceptable Kappa value. Also, 10 specialists independently evaluated the scale items. The agreement between the evaluators was calculated using the Intra-Class Correlation Coefficient (ICC) with the Two-Way Random model. Good agreement was reported between the evaluators (ICC = 0.83, P < 0.001).

Item analysis

To identify possible problems with items before construct validity, items analysis was performed on 30 young adults, 60% of whom were female, 86.7% unvaccinated, and 56.7% aged 24–26 years. Pearson correlation coefficient was used to examine the correlation between items. No significant relationship was observed between items. Alpha Cronbach of the total items was 0.769, which is acceptable [40].

Construct validity

The knowledge items (13 items) were based on literature review and were completely scientific and evidence-based. If EFA is not performed on these items, it will not reduce their validity, so they did not require EFA. The remaining attitude items (41 items) were entered into EFA and evaluated with the maximum likelihood and Promax rotation. Sample adequacy was estimated by Kaiser–Meyer–Olkin (KMO) and Bartlett tests. KMO 0.7–0.8 and 0.8–0.9 was interpreted well and excellent, respectively [41]. The sample size was estimated for factor analysis using a general rule considering 200 participants as the appropriate sample size [42]. In this study, two independent samples were collected, including 200 samples for EFA and 200 samples for CFA. A total of 400 young adults were included in the study. Demographic characteristics and HPV-related information of young adults are presented in Table 1.

Table 1 Demographic characteristics and information about HPV and HPV vaccination of participants (N = 400)
Full size table

Online data collection was done for this section. The online questionnaire was designed through the Porsline website and its URL link was sent to young adults aged 18–26 years through Telegram and WhatsApp channels. Data in Spss file were extracted from Porsline website and prepared for analysis. In order to select the appropriate variable and contribute to the formation of factors, percentage subscription equal to or greater than 0.4 were used [43]. To evaluate the structural factors, CFA was performed using the maximum likelihood method and the most common goodness-of-fit indices. The model fitness was assessed according to Parsimonious Normed Fit Index (PNFI), Root Means Square of Error of Approximation (RMSEA), Tucker–Lewis index (TLI), Incremental Fit Index (IFI), Comparative Fit Index (CFI), Parsimonious Comparative Fit Index (PCFI), and CMIN/DF.

Convergent and discriminant validity

The convergent and discriminant validity of the extracted factors were estimated to Composite Reliability (CR) and Average Variance Extracted (AVE). To establish convergent validity: (a) CR should be greater than AVE and (b) AVE should be > 0.5. To meet the discriminant validity, AVE should be > 0.5 [44].

Reliability

To evaluate the internal stability of FI(HPV)VUBYAS, Cronbach’s alpha (α) and Average Inter-item Correlation (AIC) were used, and AIC (0.2–0.4) was considered an acceptable internal consistency [45]. Then Composite Reliability (CR) and Max H reliability, which replaces Cronbach’s alpha coefficient in the SEM, were evaluated and > 0.7 value was considered acceptable [46]. The stability of FI(HPV)VUBYAS over time (test–retest) was measured using the Intraclass Correlation Coefficient (ICC) [47]. It was performed in two stages with 2 weeks’ intervals in 30 young adults. This time interval causes, on the one hand, the scale terms to be forgotten, and on the other hand, the phenomenon being measured to not be changed and values of 0.75 were acceptable [48].

Normal distribution of data, outlier data, and missing data

Before CFA, it is necessary to perform CFA assumptions, including data normality and reviewing outlier data. Given the item scores are based on the Likert scale, skewness and kurtosis coefficients were used for the normality test. The test results showed that the skewness and kurtosis scores are in the range (− 2, + 2) and have a normal distribution. Regarding outlier data, when the constructs do not have a normal distribution there are outlier data, so when the scores of all constructs have a normal distribution, there is no outlier data to examine [49, 50].

Ethical considerations

The present study was approved by the Ethics Committee of the Neuroscience Research Center of Shahid Beheshti University of Medical Sciences with the code: IR.SBMU.PHNS.REC.1397.058. Before starting the study, the general objectives were explained to the participants and informed consent was obtained from them to enter the study. All the participants, both at the interview stage and while completing the scale, were assured that their information would remain confidential.

Results

Generating items

Based on the combination of the results of the qualitative study and literature review, 1100 raw codes were extracted. In the data analysis process, after reviewing and deleting irrelevant codes, 500 primary codes were extracted. After repeated reviews, merging codes, and classifying them, 150 main codes were obtained. After reviewing, due to the great similarity between the codes, they were classified into 66 main codes, which were placed in 16 sub-categories and 8 categories. Categories included knowledge, outcome expectations, perceived threat, external stimuli, environment, responsibility, perceived barriers, and perceived stigma.

Reducing items

After performing face and content validity, the scale items were reduced from 80 to 54 (13 knowledge items and 41 attitude items). In EFA, the KMO test value was 0.875 and the Bartlett test value was 5523.990 (P < 0.001). Seven factors (38 items) were extracted and titled “external stimuli” (7 items), “perceived vulnerability” (6 items), “perceived stigma” (6 items), “perceived severity” (6 items), “outcome expectations” (4 items), “environment” (4 items), and “perceived barriers” (5 items). These 7 factors explained 57.84% of the total variance of FI(HPV)VUBYA (Table 2). Cronbach's alpha coefficient for the whole scale was calculated at 0.86 and for each factor was from 0.7 to 0.91. The scale ICC was 0.90, indicating the optimal stability of the scale (Table 3).

Table 2 the seven factors of FI(HPV)VUBYA and their factor loadings (N = 200)
Full size table
Table 3 The Cronbach’s alpha and the ICC for FI(HPV)VUBYA
Full size table

In the CFA, the chi-square fit index of 1555.056 (P < 0.001) and CMIN/DF = 2.415 were calculated. Other model fit indices were calculated and these good model fit values confirmed the final model (Table 4 and Fig. 2). The second-factor analysis was performed to confirm the latent variable of vaccination behavior. Figure 3 reveals the second-order structural model and CFA. The results of AVE, CR, and Cronbach's alpha confirmed that the second CFA model has convergent and divergent validity (Table 5). The internal consistency of the scale showed that Cronbach's alpha and ALC of all factors are greater than 0.7 and 0.5, respectively. Moreover, CR and Max H reliability of factors showed that there is a strong coefficient (Table 5). The SEM value for the scale was 6.78%, indicating that the individuals' scores on this scale tend to distribute 6.78 values around their "correct" score.

Table 4 Fit indices of the confirmatory factor analysis of the FI(HPV)VUBYAS (N = 200)
Full size table
Fig. 2
figure 2

The FI (HPV)VUBYAS construct: a model of first-order confirmatory factor analysis (N = 200)

Full size image
Fig. 3
figure 3

The FI (HPV)VUBYAS construct: a model of second-order confirmatory factor analysis (N = 200)

Full size image
Table 5 The indices of the convergent, discriminant validity and internal consistency of FI(HPV)VUBYAS for CFA(N = 200)
Full size table

Discussion

The results of this study showed that FI(HPV)VUBYAS had good validity and reliability and included 51 items and 8 factors (knowledge, external stimuli, perceived vulnerability, perceived stigma, perceived severity, outcome expectations, environment, and perceived barriers), explaining 57.84% of the total extracted variance. CFA was used in this study and confirmed the fit of the FI(HPV)VUBYAS model.

The purpose of factor extraction was to maximize variance [51], which was 57.84% in this study. The highest amount of variance was related to the external stimulus (28.01%) and perceived vulnerability (9.84%), respectively. In the study of Ali et al. (2017), which was somewhat similar to the present study, EFA was not used and no variance was reported [32]. In the study by Thomas et al. [33], psychometric assessment explained students’ opinions about HPV and its vaccine with 4 factors and 40% of the total variance [33]. Guvenc et al. [52] also reported the HPV health belief model scale and its vaccination in nursing students with 4 factors and 61.47% of the total variance [52].

According to Cronbach's alpha results, FI(HPV)VUBYAS showed strong and excellent internal consistency. FI(HPV)VUBYAS also has strong stability with an acceptable value of ICC, which is one of the advantages of this scale. In this study, the SEM scale was calculated. Measurement error is an important and required domain of COSMIN (Consensus-based standards for the selection of health Measurement Instruments) [53]. A smaller amount of SEM is very important on a scale. In fact, SEM determines the accuracy of each person's score. Previous psychometric assessment studies did not report the scale for evaluating HPV factors for this index.

Based on the factor load of the items in FI(HPV)VUBYA, 7 extracted factors (external stimuli, perceived vulnerability, perceived stigma, perceived severity, outcome expectations, environment, and perceived barriers), the first extracted factor was external stimuli. This factor consisted of 7 items reflecting the effect of others and the media on HPV vaccination in young adults. Among all the factors, external stimuli had the greatest effect on getting the vaccine. In the study by Peterson et al. [54], the effect of health care providers, peers, and social support were reported as effective factors on vaccination [54]. Emerson et al. [55] reported that parental satisfaction was effective in adolescent vaccination [55]. The second extracted factor was the 6 items perceived vulnerability, providing young adults an understanding of how they are at risk for HPV disease and cancer. These studies have shown that vulnerability to the disease plays a role in the intention of getting a vaccination [56, 57]. Several scales of HPV health belief model and HPV vaccine had this factor [33, 52]. It is important to note that although the names of the factors were similar at different scales for the HPV vaccine, they were different in terms of items.

The third factor was the perceived stigma and 6 items represented a negative association between the community, others, and health care providers with the person getting the vaccine. In a study by Jones et al. [58], it was emphasized that ethnicity and place of residence significantly affect HPV-related stigma. This was mostly reported in men who had the HPV vaccine available [58]. No scale was found to examine perceived stigma as a separate factor.

Perceived severity was the fourth extracted factor with 6 items, indicating the perceived severity of risk and damage caused by HPV in young adults, which encourage or prevent them from getting the HPV vaccine. Several scales of the HPV health belief model and the HPV vaccine reported this factor [33, 52]. However, in these scales, their perceived severity factor was different from the present study in terms of questions. In the study by Christy et al. [59], women and men who did not get the vaccine reported their perceived severity of HPV-related diseases, and their regret levels for not getting the vaccine were reported to be high [59].

The fifth extracted factor was the outcome expectations with 4 items, indicating the benefits of the young adult getting the vaccine and also the possible results of vaccination. No such a factor was reported on any scale. Thompson et al. [60] stated that the outcome expectations factor is one of the effective factors of parents on their children's HPV vaccination [60]. The sixth extracted factor was the environment with 4 items, representing the physical or social conditions of individuals, including providing educational opportunities to overcome personal and situational barriers or providing access to health services, such as vaccines. No such a factor was found in any of the scales examining HPV vaccination. Yarmohammadi et al. [61], reported education and access to vaccines as important strategies for encouraging young adults to uptake the HPV vaccine [61].

The last factor was perceived barriers with 5 items related to barriers, such as the vaccine costs, the vaccine side effects, the long intervals between three doses of the vaccine, and the long-distance from health centers. Although these are basic vaccination requirements, they are likely to affect vaccination as well. Therefore, extensive research studies have been conducted in this field [20, 62].

Limitations

The study of young adult subjects was selected from Tehran, so generalizability could be limited. The scales were also completed online and this can somewhat reduce the communication with the participants as well as the accuracy of their responses.

Conclusion

The results of this study show that FI(HPV)VUBYAS consisted of 51 items with 8 factors has acceptable validity and reliability. Based on the findings of this study, knowledge, external stimuli, perceived vulnerability, perceived stigma, perceived severity, outcome expectations, environment, and perceived barriers can be used to provide HPV vaccination services.

Availability of data and materials

The dataset generated and analyzed during the current study is not publicly available due to the highly sensitive nature of interview transcript data. Publication of entire transcripts risks identifying research participants. Data used in this study is analyzed and the data is available from the corresponding author upon reasonable request.

Abbreviations

FI(HPV)VUBYA:

Factors influencing HPV vaccine uptake behaviors in young adults

FI(HPV)VUBYAS:

Factors influencing HPV vaccine uptake behaviors in young adults scale

EFA:

Exploratory factor analysis

CFA:

Confirmatory factor analysis

HPV:

Human papillomavirus

CVR:

Content validity ratio

CVI:

Content validity index

ICC:

Intra-class correlation coefficient

KMO:

Kaiser–Meyer–Olkin

CR:

Composite reliability

References

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: Cancer J Clin. 2018;68(6):394–424.

    Google Scholar 

  2. Kurtoglu E, Ayşenur A. Cervical cancer epidemiology. Turkiye Klinikleri J Gynecol Obst-Special Topics. 2014;7(4):1–4.

    Google Scholar 

  3. WHO. Cervical cancer. World Health Organization: Geneva, 2018. http://www.whoint/cancer/prevention/diagnosis-screening/cervical-cancer/en/. Accessed 25 April 2018.

  4. Okunade KS. Human papillomavirus and cervical cancer. J Obstet Gynaecol. 2020;40(5):602–8.

    Article  CAS  PubMed  Google Scholar 

  5. Klein NP, Hansen J, Chao C, Velicer C, Emery M, Slezak J, et al. Safety of quadrivalent human papillomavirus vaccine administered routinely to females. Arch Pediatr Adolesc Med. 2012;166(12):1140–8.

    Article  PubMed  Google Scholar 

  6. Skeate JG, Woodham AW, Einstein MH, Da Silva DM, Kast WM. Current therapeutic vaccination and immunotherapy strategies for HPV-related diseases. Hum Vaccin Immunother. 2016;12(6):1418–29.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Quinn S, Goldman RD. Human papillomavirus vaccination for boys. Can Fam Phys. 2015;61(1):43–6.

    Google Scholar 

  8. Gee J, Weinbaum C, Sukumaran L, Markowitz LE. Quadrivalent HPV vaccine safety review and safety monitoring plans for nine-valent HPV vaccine in the United States. Hum vaccin immunother. 2016;12(6):1406–17.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Foundation HJKF. The HPV vaccine: access and use in the US. The Henry J. Kaiser Family Foundation San Francisco (CA); 2018.

  10. Petrosky E, Bocchini JA Jr, Hariri S, Chesson H, Curtis CR, Saraiya M, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Week Rep. 2015;64(11):300.

    Google Scholar 

  11. Vu LT, Bui D, Le HT. Prevalence of cervical infection with HPV type 16 and 18 in Vietnam: implications for vaccine campaign. BMC Cancer. 2013;13(1):1–7.

    Article  Google Scholar 

  12. Juntasopeepun P, Davidson PM, Srisomboon J. Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand. Collegian. 2012;19(1):45–50.

    Article  PubMed  Google Scholar 

  13. Kamimura A, Trinh HN, Weaver S, Chernenko A, Wright L, Stoddard M, et al. Knowledge and beliefs about HPV among college students in Vietnam and the United States. J Infect Public Health. 2018;11(1):120–5.

    Article  PubMed  Google Scholar 

  14. Dadashi M, Vaezjalali M, Fallah F, Goudarzi H, Nasiri MJ, Owlia P, et al. Epidemiology of human papillomavirus (HPV) infection among Iranian women identified with cervical infections: a systematic review and meta-analysis of national data. Infect Epidemiol Microbiol. 2017;3(2):68–72.

    Google Scholar 

  15. Khatibi M, Rasekh HR, Shahverdi Z. Cost-effectiveness evaluation of quadrivalent human papilloma virus vaccine for HPV-related disease in Iran. Iran J Pharma Res: IJPR. 2014;13(Suppl):225.

    Google Scholar 

  16. Kogan SM, Yu T, Brody GH, Allen KA. The development of conventional sexual partner trajectories among African American male adolescents. Arch Sex Behav. 2013;42(5):825–34.

    Article  PubMed  Google Scholar 

  17. Conron KJ, Goldberg SK, Halpern CT. Sexual orientation and sex differences in socioeconomic status: a population-based investigation in the National longitudinal study of adolescent to adult health. Epidemiol Commun Health. 2018;72(11):1016–26.

    Article  Google Scholar 

  18. Regmi K. Opportunities and challenges of sexual health services among young people: a study in Nepal. J Sex Med. 2009;6(2):352–61.

    Article  PubMed  Google Scholar 

  19. GoreF M, Bloem P, Patton G, Ferguson J, Joseph V, Coffey C, et al. Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet. 2011;377(9783):2093–102.

    Article  Google Scholar 

  20. Kim J, Nan X. Consideration of future consequences and HPV vaccine uptake among young adults. J Health Commun. 2015;20(9):1033–40.

    Article  PubMed  Google Scholar 

  21. Hojat M, Shariat SV, Ansari S. Iranian college students’ attitudes toward premarital sex, marriage, and family before and after the Islamic revolution. Int J Sex Health. 2015;27(3):224–34.

    Article  Google Scholar 

  22. Leung H, Lin L. Adolescent sexual risk behavior in Hong Kong: prevalence, protective factors, and sex education programs. J Adolesc Health. 2019;64(6):S52–8.

    Article  PubMed  Google Scholar 

  23. Statistical Centre of Iran. Selected results of the 2016 National population and housing census. https://www.amar.org.ir/Portals/1/census/2016/Iran_Census_2016_Selected_Results.pdf. Published August 2016.

  24. Ferrer HB, Trotter C, Hickman M, Audrey S. Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis. BMC Public Health. 2014;14(1):1–22.

    Article  Google Scholar 

  25. Boyd ED, Phillips JM, Schoenberger Y-MM, Simpson T. Barriers and facilitators to HPV vaccination among rural Alabama adolescents and their caregivers. Vaccine. 2018;36(28):4126–33.

    Article  PubMed  Google Scholar 

  26. Barnard M, George P, Perryman ML, Wolff LA. Human papillomavirus (HPV) vaccine knowledge, attitudes, and uptake in college students: Implications from the precaution adoption process model. PLoS ONE. 2017;12(8):e0182266.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  27. Wong LP, Han L, Li H, Zhao J, Zhao Q, Zimet GD. Current issues facing the introduction of human papillomavirus vaccine in China and future prospects. Human Vaccin Immunother. 2019;15(7–8):1533–40.

    Article  Google Scholar 

  28. Taebi M, Riazi H, Keshavarz Z, Afrakhteh M. Knowledge and attitude toward human papillomavirus and HPV vaccination in Iranian population: a systematic review. Asian Pac J Cancer Prev: APJCP. 2019;20(7):1945.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Malakouti J, Mirghafourvand M, Gorbani M, Poormehr HS, Shahrak SP, Shabiri MJ. Incidence of human papilloma virus (HPV) infection and its relevant factors among women referring to Alzahra therapeutic-educational center of Tabriz, September 2013 to March 2014. Iran J Obstet Gynecol Infertil. 2016;18(185):16–22.

    Google Scholar 

  30. Nekooi M, Ayazi S, Gandomi M, Moosavi SG, Fakhri A. Level of knowledge about human papillomavirus infection among women of Kashan city, Iran. Int Arch Health Sci 2016;3.

  31. Farzaneh F, Shirvani HE, Barouti E, Salehpour S, Khodakarami N, Alizadeh K. Knowledge and attitude of women regarding the human papillomavirus (HPV) infection, its relationship to cervical cancer and prevention methods. Med J Malays. 2011;66(5):468–73.

    Google Scholar 

  32. Ali N, Ping N, Prajapati S, Nazer Z, Sarriff A. Development and validation of human papilloma virus (HPV) infection and HPV vaccination questionnaire among young adults in Kedah state. Malays Madr J Pharm Res. 2017;1(1):33–9.

    Google Scholar 

  33. Thomas T, Dalmida S, Higgins M. The student human papillomavirus survey: nurse-led instrument development and psychometric testing to increase human papillomavirus vaccine series completion in young adults. J Nurs Meas. 2016;24(2):226–44.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Dib F, Mayaud P, Launay O, Chauvin P, Group F-HS. Design and content validation of a survey questionnaire assessing the determinants of human papillomavirus (HPV) vaccine hesitancy in France: a reactive Delphi study. Vaccine. 2020;38(39):6127–40.

    Article  PubMed  Google Scholar 

  35. Martinez L, Fofana F, Raineri F, Arnould P, Benmedjahed K, Coindard G, et al. Scoring and psychometric validation of the ‘determinants of intentions to vaccinate’(DIVA©) questionnaire. BMC Fam Pract. 2016;17(1):1–9.

    Google Scholar 

  36. Khamisy-Farah R, Adawi M, Jeries-Ghantous H, Bornstein J, Farah R, Bragazzi NL, et al. Knowledge of human papillomavirus (HPV), attitudes and practices towards anti-HPV vaccination among Israeli pediatricians, gynecologists, and internal medicine doctors: development and validation of an ad hoc questionnaire. Vaccines. 2019;7(4):157.

    Article  PubMed Central  Google Scholar 

  37. Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. Ectj. 1981;29(2):75–91.

    Article  Google Scholar 

  38. Lenz ER. Measurement in nursing and health research: Springer publishing Company; 2010.

  39. Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975;28(4):563–75.

    Article  Google Scholar 

  40. Ebadi A, Zarshenas L, Rakhshan M, Zareiyan A, Sharifnia S, Mojahedi M. Principles of scale development in health science. Tehran: Jame-e-negar; 2017.

    Google Scholar 

  41. Nia HS, Ebadi A, Lehto RH, Mousavi B, Peyrovi H, Chan YH. Reliability and validity of the persian version of templer death anxiety scale-extended in veterans of Iran-Iraq warfare. Iran J Psychiatr Behav Sci. 2014;8(4):29.

    Google Scholar 

  42. MacCallum RC, Widaman KF, Zhang S, Hong S. Sample size in factor analysis. Psychol Methods. 1999;4(1):84.

    Article  Google Scholar 

  43. Hahs-Vaughn DL. Applied multivariate statistical concepts: Routledge; 2016.

  44. Ahadzadeh AS, Sharif SP, Ong FS, Khong KW. Integrating health belief model and technology acceptance model: an investigation of health-related internet use. J Med Internet Res. 2015;17(2):e3564.

    Article  Google Scholar 

  45. Mohammadbeigi A, Mohammadsalehi N, Aligol M. Validity and reliability of the instruments and types of measurments in health applied researches. J Rafs Univ Med Sci. 2015;13(12):1153–70.

    Google Scholar 

  46. Sharif Nia H, Shafipour V, Allen K-A, Heidari MR, Yazdani-Charati J, Zareiyan A. A second-order confirmatory factor analysis of the moral distress scale-revised for nurses. Nurs Ethics. 2019;26(4):1199–210.

    Article  PubMed  Google Scholar 

  47. Javali SB, Gudaganavar NV, Raj SM. Effect of varying sample size in estimation of coefficients of internal consistency. Webmed Central [Internet]. 2011. https://doi.org/10.9754/journal.wmc.2011.001649.

    Article  Google Scholar 

  48. Miremadi M, Bandari R, Heravi-Karimooi M, Rejeh N, Sharif Nia H, Montazeri A. The Persian short form aging perceptions questionnaire (APQ-P): a validation study. Health Qual Life Outcomes. 2020;18(1):1–9.

    Article  Google Scholar 

  49. DeVellis RF, Thorpe CT. Scale development: theory and applications: Sage publications; 2021.

  50. Esposito Vinzi V, Chin WW, Henseler J, Wang H. Handbook of partial least squares: concepts, methods and applications: Heidelberg, Dordrecht, London. New York: Springer; 2010.

    Book  Google Scholar 

  51. Polit DF, Yang F. Measurement and the measurement of change: a primer for the health professions. Philadelphia: Wolters Kluwer; 2016.

    Google Scholar 

  52. Guvenc G, Seven M, Akyuz A. Health belief model scale for human papilloma virus and its vaccination: adaptation and psychometric testing. J Pediatr Adolesc Gynecol. 2016;29(3):252–8.

    Article  PubMed  Google Scholar 

  53. Terwee CB, Mokkink LB, Knol DL, Ostelo RW, Bouter LM, de Vet HC. Rating the methodological quality in systematic reviews of studies on measurement properties: a scoring system for the COSMIN checklist. Qual Life Res. 2012;21(4):651–7.

    Article  PubMed  Google Scholar 

  54. Peterson CE, Silva A, Holt HK, Balanean A, Goben AH, Dykens JA. Barriers and facilitators to HPV vaccine uptake among US rural populations: a scoping review. Cancer Causes Control. 2020;31(9):801–14.

    Article  PubMed  Google Scholar 

  55. Emerson A, Allison M, Kelly PJ, Ramaswamy M. Barriers and facilitators of implementing a collaborative HPV vaccine program in an incarcerated population: a case study. Vaccine. 2020;38(11):2566–71.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Richards K. Intention of college students to receive the human papillomavirus vaccine. Health Education. 2016.

  57. MacArthur KR. Beyond health beliefs: the role of trust in the HPV vaccine decision-making process among American college students. Health Soc Rev. 2017;26(3):321–38.

    Article  Google Scholar 

  58. Jones G, Perez S, Huta V, Rosberger Z, Lebel S. The role of human papillomavirus (HPV)-related stigma on HPV vaccine decision-making among college males. J Am Coll Health. 2016;64(7):545–54.

    Article  PubMed  Google Scholar 

  59. Christy SM, Winger JG, Raffanello EW, Halpern LF, Danoff-Burg S, Mosher CE. The role of anticipated regret and health beliefs in HPV vaccination intentions among young adults. J Behav Med. 2016;39(3):429–40.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Thompson EL, Rosen BL, Vamos CA, Kadono M, Daley EM. Human papillomavirus vaccination: what are the reasons for nonvaccination among US adolescents? J Adolesc Health. 2017;61(3):288–93.

    Article  PubMed  Google Scholar 

  61. Yarmohammadi S, Ghaffari M, Mashayekhi P, Ramezankhani A, Mirzaei J. Strategies for improving participation in human papillomavirus vaccination among young adults in the capital of Iran: a qualitative–exploratory study. Int J Prev Med. 2022;13(1):1.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Vu M, King AR, Jang HM, Bednarczyk RA. Practice-, provider-and patient-level facilitators of and barriers to HPV vaccine promotion and uptake in Georgia: a qualitative study of healthcare providers’ perspectives. Health Educ Res. 2020;35(6):512–23.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The research team would like to thank the School of Health and Safety of Shahid Beheshti University of Medical Sciences for supporting this study. They also would like to thanks the study of specialists and young adults.

Funding

This study is funded by a research grant from the School of Health and Safety of Shahid Beheshti University of Medical Sciences. The funding body (SBMU) didn’t have any role in the design of the study and collection, analysis, and interpretation of data, and in the writing the manuscript.

Author information

Authors and Affiliations

  1. School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Soudabeh Yarmohammadi

  2. Environmental and Occupational Hazards Control Research Centre, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Mohtasham Ghaffari

  3. Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Yadollah Mehrabi

  4. Department of Epidemiology and Biostatistics, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran

    Samira Mousavi

  5. Department of Public Health, School of Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    Ali Ramezankhani

Authors
  1. Soudabeh Yarmohammadi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mohtasham Ghaffari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yadollah Mehrabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Samira Mousavi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ali Ramezankhani
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AR and MG: Conception and design of the study, data analysis and interpretation, and manuscript writing. SY: Conception and design of the study, data collection, data analysis and interpretation, and writing up the manuscript. YM and SM: design of the study, data analysis and interpretation, and critical revision of the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Ali Ramezankhani.

Ethics declarations

Ethics approval and consent to participate

We received approval from the Ethics Committee for this study from the Neuroscience Research Center of Shahid Beheshti University of Medical Sciences with the code: IR.SBMU.PHNS.REC.1397.058. All these methods followed relevant guidelines, literature review, and regulations approved by the School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Written informed consent was obtained from all participants prior to taking part in this study.

Consent for publication

Not applicable.

Competing interests

The authors express that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yarmohammadi, S., Ghaffari, M., Mehrabi, Y. et al. Designing and psychometric assessment of the scale of factors influencing HPV vaccine uptake behaviors in young adults. Infect Agents Cancer 17, 48 (2022). https://doi.org/10.1186/s13027-022-00461-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13027-022-00461-z

Keywords

Infectious Agents and Cancer

ISSN: 1750-9378

Contact us