Two Web-Based and Theory-Based Interventions With and Without Brief Motivational Interviewing in the Promotion of Human Papillomavirus Vaccination Among Chinese Men Who Have Sex With Men: Randomized Controlled Trial

"[H]ealth workers in Hong Kong were provided with an evidence-based intervention for promoting HPV vaccination among MSM."

In Hong Kong, human papillomavirus (HPV) vaccination, which can prevent genital warts and some cancers, is very low among males, and previous studies have reported zero uptake among a group vulnerable to HPV infection: men who have sex with men (MSM). This randomised controlled trial (RCT) evaluated the relative efficacies of 2 web- and theory-based interventions with and without brief motivational interviewing (MI) over the phone. MI is a client-centred, nondirective, goal-oriented counseling technique that can help clients explore and resolve any ambivalence that might have to change. The goal was to determine how best to increase the completion of HPV vaccination within a 24-month follow-up period among unvaccinated Hong Kong Chinese MSM compared with a control group.

A key theory on which the RCT was based is the health belief model (HBM), whose constructs include perceived susceptibility (e.g., risk of HPV, genital warts, and penile or anal cancer), perceived severity (e.g., chance of HPV infection causing genital warts and penile or anal cancers), perceived benefit of HPV vaccination (e.g., efficacy in preventing genital warts and penile or anal cancers), perceived barriers (e.g., high cost, potential side effects, and embarrassment), and cue to action (e.g., recommendation by doctor or peers to get vaccinated).

The process of developing the approach for the trial was participatory. Prior to the RCT, a panel comprising 3 MSM volunteers, 2 epidemiologists, 1 health psychologist, 1 health communication expert, 2 non-governmental organisation (NGO) workers, and 1 video producer was formed. A literature review and a discussion group that involved 5 MSM were conducted to inform the design of the web-based health communication messages. The web-based tutorial video was produced by a professional team, reviewed by 3 other MSM, and finalised by the panel.

In addition, fieldworkers received 2 full days of basic MI training and participated in role-plays over the phone to increase their confidence. Fieldworkers also took part in a 4-hour training workshop about background knowledge of local MSM, HPV-related diseases, and HPV vaccination. Regular meetings for problem solving and improvements were held, and fieldworkers sought support from the trainer via phone calls during the project period.

The 3-arm parallel-group RCT was conducted between July 2017 and December 2019. It involved 624 Hong Kong Chinese-speaking MSM aged between 18 and 45 years with regular internet access who were recruited through outreach at venues frequently visited by local MSM, gay websites, and peers. Those who had ever received HPV vaccination were excluded. The participants were randomised into either the online tutorial (OT) only group (n=208), the OT plus MI group (OT-MI; n=208), or the control group (n=208):

• OT group: The first part of the OT was a 5-minute web-based video, whose contents were based on theory-based factors associated with the acceptability of HPV vaccination among local MSM and guided by the HBM. It featured a peer MSM discussing issues such as the long protection duration of HPV vaccination in the prevention of genital warts and penile or anal cancers. Flashes of related scary images were shown in the video to increase perceived severity. The second part of the OT was a self-administered exercise featuring web-based multiple choice questions (e.g., knowledge of HPV and HPV vaccination) and a short exercise to modify related cognitions (e.g., "Please list three potential benefits you will gain after taking up HPV vaccination.").
• OT-MI group: In addition to the above OT, participants received a 15-minute MI session via telephone.
• Control group: Participants received a link to access web-based health communication messages (e.g., about the prevalence of mental health problems among MSM) that were totally unrelated to HPV or HPV vaccination.

Reminders were sent to the participants of the OT and OT-MI groups after 1, 2, 4, 6, and 8 months. Five telephone surveys were conducted at baseline and at 3, 6, 9, and 24 months by blinded interviewers. In total, 459 (459/624, 73.6%) completed the follow-up evaluation at 24 months. The research team validated the self-reported HPV vaccination uptake.

The study found that participants in the OT-MI group reported a significantly higher validated completion of HPV vaccination at 24 months than the control group (36/208, 17.3% vs 15/208, 7.2%; P=.006). However, the difference in HPV vaccination completion between the OT and the control groups (24/208, 11.5% vs 15/208, 7.2%; P=.17), or between OT-MI and OT groups (P=.13), was not statistically significant.

The association between randomisation status (OT-MI group vs control group) and HPV vaccination completion became statistically nonsignificant after controlling for changes in the perceived susceptibility to HPV (24 months vs baseline), whereas perceived susceptibility remained strongly associated with HPV vaccination uptake in the model (P<.001). That is, the behavioural change may be caused by an increase in perceived susceptibility to HPV or HPV-related diseases. The researchers report that this finding is consistent with studies that have demonstrated a strong association between risk perception and behavioural change in different health topics.

In the absence of intervention, perceived barriers to taking up HPV vaccination increased over time in the control group. Receiving OTs and brief MI over the phone slowed down the increase in perceived barriers. The between-group (OT-MI vs control) difference in changes of perceived barriers partially mediated the intervention effects.

Among those in the OT and OT-MI groups who participated in a process evaluation at 3 months, 84.1% (281/334) and 46.1% (154/334) believed that the content of the web-based health promotion video was clear and attractive. Moreover, 77.2% (258/334) and 47.0% (157/334) indicated that the OT increased their understanding of HPV vaccination and willingness to take up HPV vaccination. Among those in the OT-MI group, 86.8% (159/182) were satisfied with the MI session, and 60.9% (111/182) believed the MI session reduced their barriers toward getting HPV vaccination.

The researchers indicate that OT required minimum resources for maintenance and that, with simple training, health workers can easily perform brief MI. Therefore, governmental organisations and NGOs could integrate this intervention into their existing HIV or sexually transmitted infection (STI) prevention services and scale it up with little extra cost.

In conclusion: "Theory-based OT with brief MI over the phone was effective in increasing HPV vaccination completion among Chinese MSM. Perceived susceptibility is an active theoretical component that causes behavioral changes."