Health Psychology

2010, Vol. 29, No. 1, 29 39

2010 American Psychological Association

0278-6133/10/$12.00 DOI: 10.1037/a0016942

Behavioral Interventions to Increase HPV Vaccination Acceptability

Among Mothers of Young Girls
Dena S. Cox, Anthony D. Cox, Lynne Sturm, and Greg Zimet
Indiana University
Objective: To determine the most effective ways to present human papillomavirus (HPV) vaccine risk and
benefit information to mothers in Hispanic, African American, and White communities, to increase mothers
intentions to vaccinate their daughters against HPV. Design: The study used a 3 2 between-subjects
factorial design, involving 3 different risk presentation formats (graphical HPV statistics, nongraphical HPV
statistics, or no-statistics control) and the presence or absence of rhetorical questions (RQ). Data were collected
from a national sample of 471 mothers of girls ages 1116. Main Outcome Variables: The primary outcome
variable was mothers intention to vaccinate their daughters against HPV. Secondary outcomes included
mothers self-reported message comprehension and perceptions of daughters vulnerability to HPV infection,
infection severity, vaccine efficacy, and obstacles to immunization. Results and Conclusion: Results showed
that both risk presentation format and RQs had an overall positive effect on mothers intention to vaccinate
their daughters. However, the interventions appear to be more effective when used separately than when used
in combination. Each of these interventions is brief and could easily be implemented by health care providers
as well as in patient health communication literature.
Keywords: behavioral interventions, HPV vaccination intentions, graphical risk presentation, rhetorical
question (foot in the door), health communication

senting HPV risk and vaccine efficacy information and (b) test the
effectiveness of a social compliance technique (rhetorical questions; RQs) in increasing acceptability to mothers of vaccinating
their daughters against HPV infection.

In June 2006, a vaccine to prevent infection with four human

papillomavirus (HPV) types, including two causing cervical cancer, was licensed by the U.S. Food and Drug Administration
(FDA; Centers for Disease Control & Prevention, 2007). This
vaccine has important public health implications for women, especially for low-income and minority women, for whom cervical
cancer risk is especially high. However, the vaccines potential
public health benefits will be realized only if they are widely
understood by parents and if large numbers decide to have their
daughters vaccinated. This study seeks to determine the most
effective ways to present HPV vaccine information to parents, to
encourage adherence to HPV vaccination recommendations for
adolescent and preadolescent girls. Using social psychological
research in social compliance, and research on the visual presentation of risk information, this study uses a randomized experiment
to (a) test alternative methods (graphic and nongraphic) for pre-

Literature Review
HPV Infection and Vaccination
HPV infection is the major cause of cervical cancer, with two
HPV types (16 and 18) causing about 70% of all cervical cancers
(International Agency for Research on Cancer [IARC], 1995;
Kuper, Adams, & Trichopoulos, 2000). In the United States, about
10,000 women are diagnosed with cervical cancer annually and
nearly 4,000 die from it; worldwide, the disease afflicts nearly half
a million women each year, causing about 250,000 deaths (National Cancer Institute [NCI], n.d.-a). For women with regular
access to health care, cervical cancer mortality can be greatly
reduced by regular Pap tests (Sanders & Taira, 2003). Still, this
disease exacts substantial health and economic costs, suggesting
that widespread HPV vaccination could prove cost effective
(Elbasha, Dasback, & Insinga, 2007; Kulasingam et al., 2006),
particularly among preadolescent girls (Kim & Goldie, 2008).
HPV vaccination may be especially beneficial to Hispanic and African American women, who are less likely to get regular Pap tests
(Huerta, 2003; OBrien et al., 2003). In the United States, cervical
cancer incidence per 100,000 women is 6.6 among non-Hispanic
Whites, but much higher among Hispanic (12.6) and African American (9.2) women (National Cancer Institute [NCI], n.d.-b).
In June 2006, the FDA licensed the first HPV vaccine, for use
in girls and women ages 9 26. Soon thereafter, the Advisory
Committee on Immunization Practice (ACIP) recommended rou-

Dena S. Cox and Anthony D. Cox, Indiana University Kelley School of

Business; Lynne Sturm and Greg Zimet, Department of Pediatrics, Indiana
University School of Medicine.
This study was partially supported by funds to the first author from the
Kelley School of Business, Indiana University.
Gregory Zimet serves as co-principal investigator and co-investigator
respectively on two investigator-initiated research grants funded by Merck
that involve studies of HPV vaccine acceptability and acceptance. In 2008,
Gregory Zimet served as a paid research consultant on a Merck research
study of HPV vaccine acceptability and acceptance.
The authors would like to thank the two anonymous reviewers of this
paper for their thoughtful comments.
Correspondence concerning this article should be addressed to Dena S.
Cox, Kelley School of Business, Indiana University, 801 Michigan Street,
Indianapolis, IN 46202-5151. E-mail: dcox@iupui.edu
29

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COX, COX, STURM, AND ZIMET

tine HPV vaccination for girls ages 11 and 12 and catch-up

vaccination for older girls and young women (Centers for Disease
Control & Prevention, 2007). In the ensuing months, efforts were
made in some states to mandate HPV vaccination for school entry.
However, these efforts generated considerable backlash, making
widespread school mandates unlikely. Thus, for the foreseeable
future, the ability of the HPV vaccine to reduce cervical cancer in
the United States will depend on provision of the vaccine by health
care providers and individual parents deciding to have their daughters vaccinated.
In recent years, several descriptive studies have examined parents beliefs and attitudes toward HPV vaccination (see the review
by Zimet, Shew, & Kahn, 2008), but surprisingly few experimental
studies have examined alternative approaches to communicating
the vaccines risks and benefits to parents. In one of the few such
studies, Dempsey, Zimet, Davis, and Koutsky (2006) examined the
effect of an educational intervention on HPV vaccine acceptability
among parents of 8- to 12-year-olds. Although the intervention
increased parents HPV knowledge, it had no impact on vaccination acceptability. In contrast, Davis, Dickman, Ferris, and Dias
(2004) found that HPV information increased parents support for
adolescent HPV vaccination. More recently, both Gerend and
Shepherd (2007) and Leader, Weiner, Kelly, Hornik, and Cappella
(2009) found evidence that HPV message framing influences
self-vaccination intentions among adult women; however, neither
study presented evidence of message effects on parents intentions
to vaccinate their daughters. (The Gerend and Shepherd study
focused solely on college-age women, while the Leader et al. study
sample included very few parents of young daughters.)

Research on Graphic Versus Nongraphic Presentation

of Risk Information
A parents decision to vaccinate (or not vaccinate) her child can
be influenced by a number of factors, including perceived social
norms regarding vaccination, provider recommendation, and the
perceived risks and benefits of vaccination (see, e.g., Sturm, Mays,
& Zimet, 2005). For those parents seeking to assess a specific
vaccines risks and benefits, it is important that they clearly understand the relative likelihood of different events: For example,
How likely is my daughter to get cervical cancer during her
lifetime? and How will this likelihood change if she receives the
HPV vaccination? Without an understanding of relative risk
probabilities, parents may overestimate extremely low-likelihood
risks (e.g., a life-threatening vaccine reaction) and underestimate
much higher likelihood events (e.g., contracting the disease the
vaccine is intended to prevent).
In presenting such risk information, one has essentially three
options: verbal, numerical, and graphic. Verbal communication of
risk (using adjectives such as rare or common) is popular but
problematic. First, such words are inherently ambiguous, leading
to widely divergent interpretations (Berry, 2004; Bonnefon &
Villejoubert, 2006). Second, lay interpretations of risk terms often
deviate dramatically from the intent of risk communicators. For
example, risk communication guidelines issued by the European
Commission dictate that a drugs side effect should be described as
very rare if it occurs in less than 0.01% of patients (Berry, 2004).
However, Cox and Cox (2007) found that consumers encountering
these terms in prescription drug advertisements interpreted them

quite differently. For example, when a side effect was described as

very rare, participants indicated that it would occur in over 30% of
patients only slightly less often than a side effect described as
very common.
Numerical presentations of likelihoods (e.g., odds, percentages,
and probabilities) have the advantage of greater precision but also
present communication problems. Research suggests that many
people find percentages and probabilities to be confusing (Berry,
2004; Tversky & Kahneman, 1981). In addition, research (e.g.,
Cox & Cox, 2001) suggests that audiences often perceive numerical information to be uninteresting and uninvolving and therefore
may tend simply to disregard it when making decisions.
One possible method to overcome some of these problems is the
graphic presentation of risk likelihoods. Previous research suggests
that graphic risk presentations are often easier to understand
(Chua, Yates, & Shah, 2006; Edwards, Elwyn, & Gwyn, 1999;
Lipkus & Hollands, 1999; Stone, Yates, & Parker, 1997; Waters,
Weinstein, Colditz, & Emmons, 2006), can be processed more
rapidly (Paivio, 1971), may help people tolerate low-probability
risks (Stone et al., 1997), and often increase intention to adopt
risk-reduction behaviors (Chua et al., 2006). Recently, Wallace,
Leask, and Trevena (2006) found that an online decision aid using
graphic information on risks of the measles-mumps-rubella vaccine increased parents intentions to vaccinate their children.
Graphic risk presentation may be particularly helpful for those
with less education, those with low numerical fluency, and those
whose first language is not English.
We expect the effect of risk presentation on parents vaccination
intentions to be mediated by components of the Health Belief
Model (Becker, 1974; Rosenstock, 1966). For example, perceived
HPV vulnerability and severity have been shown to influence
vaccine acceptance among parents (Ferris, Waller, Owen, &
Smith, 2008; Olshen, Woods, Austin, Luskin, & Bauchner, 2005).
Perceived vaccine efficacy and obstacles were also shown to
influence vaccine acceptance (Gerend, Lee, & Shepherd, 2007;
Zimet, 2005).
On the basis of the literature, we expect that graphic presentation of HPV risk information will increase both reported message
comprehension and vaccination intention, in comparison with nongraphic or control conditions. We also expect that the effects of
risk presentation on mothers vaccination intention will be mediated by perceived HPV vulnerability and severity, vaccine efficacy, and vaccination obstacles.
Schwartz, Woloshin, Black, and Welch (1997) found that participants scoring low on numerical fluency (or numeracy) had
more difficulty interpreting medical statistics. Because a potential
benefit of graphic risk presentation is ease of understanding, we
expect that numeracy will moderate the effect of graphic presentation on self-reported message comprehension and HPV vaccine
intention; that is, the effects of graphic presentation on comprehension and vaccination intent will be strongest among mothers
with low numeracy scores.

Research on Rhetorical Question (RQ) Technique

Another intervention that may be helpful in increasing HPV
vaccine acceptance is the rhetorical question (RQ) technique (Cialdini, Trost, & Newsom, 1995; Freedman & Fraser, 1966). This
intervention (also known as foot in the door) involves gaining

INTERVENTIONS TO INCREASE HPV VACCINATION

agreement with a small, high-compliance request or question before making a larger (target) request. The theory is that after
respondents agree to the initial request, they are more likely to
agree to the larger request, in order to seem consistent in their
behavior. For example, people may be more likely to donate to an
environmental cause (large request), if first asked to sign a proenvironmental petition (small request). This is typically explained in
terms of self-perception: agreeing to the initial request changes
ones self-concept (Because I signed the petition, I must support
the environment.); then when faced with the second request, one
feels a need to be consistent with the initial behavior (Because I
support the environment, I probably should give some money.).
Dolin and Booth-Butterfield (1995) published one of the few
studies to apply the RQ method to changing health behavior.
Women attending a health fair were asked to schedule a gynecological exam. However, prior to this request, half the women were
asked if they wanted a breast self-exam demonstration card (all of
them said yes). Among women offered the card, 41% later
scheduled an exam, in comparison with 25% in the control condition. Interestingly, women in the RQ group had slightly less
favorable attitudes toward gynecological exams than did the controls but were more likely to actually sign up for one. Interpretation
of this study is complicated by a possible confound: the mere
receipt of a gift may have increased adherence, because people
who receive gifts often feel obligated to reciprocate (Cialdini,
1988). Our study remedies this limitation, by using a RQ intervention that does not involve a gift.
On the basis of the literature, we expect that mothers asked RQs
about protecting their daughters health will express stronger intentions to vaccinate their daughters against HPV, in comparison
with mothers not asked RQs. Furthermore, we expect the effects of
RQ on vaccination intention to be mediated by perceptions of HPV
vulnerability and severity and of vaccination efficacy and obstacles.
Cialdini et al. (1995) argued that compliance with a small
request should have the greatest impact on the subsequent behavior
of people with a high need for internal consistency. Thus we
expect that need for consistency will moderate the effect of the
rhetorical question on HPV vaccine intention; that is, that the
effects of the RQ intervention will be strongest among mothers
scoring high on need for consistency.

Summary of Hypotheses
Hypothesis 1: Graphic presentation of risk statistics, in comparison with both nongraphic statistics and a no-statistics
control, will increase mothers (a) intention to have their
daughters receive the HPV vaccine and (b) self-reported
message comprehension.
Hypothesis 2: The effects of risk presentation on mothers
vaccination intention will be mediated by perceptions of their
daughters vulnerability to HPV infection, HPV severity,
vaccine efficacy, and obstacles to immunization.
Hypothesis 3: The effects of risk presentation will be moderated by mothers numeracy; that is, the positive effects of
graphic presentation on message comprehension and vacci-

31

nation intention will be stronger among mothers with low

numeracy scores.
Hypothesis 4: Mothers asked rhetorical questions (RQs)
about protecting their daughters health will report greater
intention to vaccinate their daughters than will mothers not
asked RQs.
Hypothesis 5: The effects of RQ on vaccination intention will
be mediated by perceived vulnerability to HPV infection,
HPV severity, vaccine efficacy, and obstacles to immunization.
Hypothesis 6: The effects of RQ will be moderated by need
for consistency; that is, the effects of RQ will be strongest
among mothers with high need-for-consistency scores.

Method
Sample
A total of 522 mothers of girls ages 1116 years were recruited
from a national online survey panel purchased from a commercial
sample vendor, Survey Sampling International (SSI). SSI maintains a national panel of over 1 million potential respondents. For
each study, SSI sends e-mail invitations to a random subset of
those panel members meeting the studys demographic criteria.
Volunteers are placed by SSI into a lottery to win a monetary prize,
to increase response rates. Panel members can complete a maximum of four surveys per year. Because researchers do not know
respondents identities, responses are completely anonymous.
Given the importance of HPV vaccination in lowsocioeconomic
status (SES) and minority populations, we asked SSI to oversample these groups by using quota sampling. The final sample
was 21% African American, 20% Hispanic, and 56% with a high
school diploma or less (see Table 1).
After initial recruitment by SSI, each potential respondent was
directed to a web survey (housed on the Indiana University server),
which first asked if she was a custodial parent of a girl between
ages 11 and 16. If not, she was thanked and excluded from the
study. Mothers also were excluded from analysis if they reported
that their daughters had already received the HPV vaccine. Of 522
mothers recruited, 19 were excluded because their daughters had
already had at least one HPV shot, 21 were excluded because they
were not a custodial parent, and 11 had missing values on key
variables. Thus, a final usable sample of 471 mothers completed
the survey.

Experimental Design
The study used a 3 2 between-subjects factorial design, in
which participants were assigned randomly to one of three risk
presentation formats (graphic HPV statistics, nongraphic HPV
statistics, or no-statistics control) and the presence or absence of a
rhetorical question (RQ). The studys design and procedure were
approved by the institutional review board at Indiana University.

Interventions
The rhetorical question intervention comprised two yesno
questions: Do you want to protect your daughter from cancer?

COX, COX, STURM, AND ZIMET

32

Table 1
Baseline Characteristics of Total Sample and Experimental Groups
Experimental group
Graphic statistics
Characteristic
Daughters mean age (in years)
Mothers education
Not finish HS
HS graduate
Some college
Trade school
College graduate or more
Mothers ethnicity
African American
Hispanic
Non-Hispanic White
Other ethnicities
Mothers age (in years)
1834
3544
45 or older

Total sample

RQ

No RQ

Nongraphic statistics
RQ

No RQ

No statistics control
RQ

No RQ

13.7

13.6

13.6

13.8

13.8

13.7

13.6

.94

4.9%
50.8%
22.2%
5.8%
16.3%

4.4%
50.5%
25.3%
2.2%
17.6%

2.8%
55.6%
25.0%
2.8%
13.9%

4.1%
47.3%
28.4%
4.1%
16.3%

8.6%
44.4%
21.0%
7.4%
18.5%

2.8%
59.7%
15.3%
5.6%
16.7%

6.7%
48.0%
17.3%
13.3%
14.7%

.34

21.4%
19.7%
58.4%
1%

23.1%
20.9%
56.0%

18.9%
24.3%
56.8%

28.0%
18.7%
52.0%

19.5%
15.9%
64.6%

17.8%
15.1%
65.8%

21.1%
23.7%
55.3%

.58

2.1%
64.5%
33.3%

4.4%
64.4%
31.1%

0.0%
60.3%
39.7%

2.6%
61.3%
36.0%

3.7%
66.7%
29.6%

1.4%
68.5%
30.1%

0.0%
65.8%
34.2%

.60

Note. RQ rhetorical question; HS high school.

The p values for are for chi-squared analysis, except for daughters age ( p value for students t statistic).

and If there was a vaccine to protect your daughter against cancer,

would you have her get it? Consistent with the foot-in-the-door
paradigm, these initial questions were designed to (a) elicit high
agreement levels (99.6% said yes to the first question, 90% to
the second question) and (b) gain respondents commitment to a
broad principal (cancer prevention) consistent with the target behavior (HPV vaccination).
The risk-information intervention consisted of two components: First, all study participants (including those in the nostatistics control condition) were given basic, nonstatistical
information about cervical cancer, HPV infection, and the HPV
vaccine, drawn from the Centers for Disease Control (CDC)
website. The following is the baseline HPV information given
to all participants:
Cervical cancer is a life-threatening disease that affects women.
Cervical cancer is caused by a virus called Human Papillomavirus
(HPV). HPV is one of the most common sexually transmitted
infections.
There is a new vaccine to prevent HPV infection in young women and
girls. Girls who get this vaccine now are much less likely to get
cervical cancer later in life. In addition, the vaccine prevents most
cases of genital warts, which are also caused by HPV infection.
The HPV vaccine is approved for use by girls and women between the
ages of 9 and 26. However, it is best to vaccinate girls in their
childhood or early teens, before they become sexually active.
The HPV vaccine is generally safe. As with most shots, the most
common side effects are pain, swelling, itching or redness at the
injection site. Very rarely, difficulty breathing has been reported.
The HPV vaccine is given in three shots over a 6-month period. After
a girl gets her first shot, she should come back in 2 months for her
second shot, and in another 4 months for her third shot.

For participants in the no-statistics control condition, this was

the only HPV information received. However, participants in the

two statistical conditions (graphic and nongraphic) were also given

the numerical information on the risks of cervical cancer and the
efficacy of the HPV vaccine. The following is the statistical HPV
information given to participants in the graphic and nongraphic
statistics conditions:
Girls who get the HPV vaccine are much less likely to get cervical
cancer later in life. Right now, there are 12 million American girls
between the ages of 11 and 16. If none of these girls get the HPV
vaccine, about 87,000 will get cervical cancer later in life. Thats
enough to fill a football stadium. If all girls get the HPV vaccine,
only about 27,000 will get cervical cancer. So the HPV vaccine
would save 60,000 girls from getting cancer later in life.

The statistical HPV risk information was based on the most

current data on the lifetime risk of cervical cancer among American women (from the National Cancer Institute [NCI] SEER
database) and the efficacy of the quadrivalent HPV vaccine (Centers for Disease Control & Prevention, 2007; Villa, Perez, Kjaer, et
al., 2007). The length of protection provided by the HPV vaccine
is known to be at least 6 years and is expected to extend well
beyond this period of time (Fraser et al., 2007; Olsson et al., 2007;
Villa et al., 2006); however, the precise lifetime efficacy of the
HPV vaccine in preventing cervical cancer will not be known with
certainty for decades.

Development and Pretest of Graphic Stimuli

Next, we developed a graphic depiction of the statistical information, working with a medical-graphics design firm. In designing
these graphics, we sought a familiar reference point to help mothers visualize the absolute number of girls who would get cervical
cancer with and without the vaccine. Thus, rather than using bar or
pie charts (which present relative risk information but no familiar
reference point to judge absolute numbers), we developed a sta-

INTERVENTIONS TO INCREASE HPV VACCINATION

dium graphic that used contrasting colors to depict the number of

vaccine recipients who would be saved from cervical cancer,
versus those who still get cervical cancer. We created four prototypes of this graphic, varying in color scheme and layout: (a) green
to depict saved and red to depict got cancer; (b) red for saved and
green for got cancer; (c) gray tones instead of color; and (d) a
graph similar to that in prototype a but reversing the leftright
position of get cancer and saved.
Next, we pretested the four graphic prototypes for potential
differences in message evaluation and vaccination intention. The
pretest sample consisted of 206 mothers of girls ages 1116 years
(none of whom participated in the main study), recruited by SSI
and directed to a brief Web survey. The sample was 13% African
American, 10% Hispanic, and 51% with a high school diploma or
less. All respondents were first given the baseline, nonstatistical
HPV information (see above) and then assigned randomly by the
Web survey program to one of the four alternative graphic formats.
Next, participants completed Likert scales for message believability (This information seemed believable), ease of understanding
(This information was easy to understand), usefulness (This
information was useful to me), and relevance (This information
was relevant to me) as well as intention to have their daughters
get the three HPV vaccine doses (three 5-point scales; 5 definitely would get vaccinated, 1 definitely would not get vaccinated). An analysis of variance (ANOVA) revealed no significant
differences among the four graph versions on any of the message
characteristics or intention. Thus, the stadium graphic appears to elicit
similar responses regardless of the specific colors, or the leftright
layout. For the main study, we chose the graphic that used red for got
cancer and green for saved. This color representation draws on
common associations from everyday life (e.g., green and red of traffic
lights) in which red signals warning and green normal.
Figure 1 shows the graphic and nongraphic risk messages used
in the main study. As can be seen, the text (content, size, and
spacing) was identical in these two conditions; the only difference
was the presence or absence of the stadium graphic.

Procedure for Main Study

For the main study, potential participants recruited by SSI were
directed to a Web survey. The first question was a screener,
confirming that the respondent was the custodial parent of a girl
between the ages of 11 and 16 years. Next, half of the participants
(randomly assigned by the interview program) were asked the two
rhetorical questions, while half were not. Next, all participants
received the basic (nonstatistical) HPV information. Next, participants were randomly assigned to one of three risk-presentation
groups: nongraphic risk presentation, graphic risk presentation, or
a no statistics control group that skipped to the next section. Next,
all participants were told that if they had more than one daughter
in the age range, to think about only one daughter with respect to
subsequent questions. Then, mothers were asked the age of that
daughter. Finally, participants completed a series of measurement
scales, discussed in the next section.

Main Outcome Measures

The primary outcome variable was mothers intention to have
their daughters receive the three HPV vaccine doses. Intention

33

was measured with three questions, each using a 5-point scale

anchored by I definitely would NOT have her get the first
[2nd, 3rd] shot and I definitely would have her get the first
[2nd, 3rd] shot (Jamieson & Bass, 1989). The sum of these
three items formed the measure Total shot intention with a
coefficient alpha of .99.
Next, secondary outcomes were measured, beginning with
respondents HPV-related health beliefs (Becker, 1974; Rosenstock, 1966), all measured with summed 7-point Likert scales.
Perceived severity of HPV infection was measured with a
four-item scale with coefficient .84 (e.g., Infection with
HPV can lead to a serious illness, and HPV can cause cervical
cancer). Perceived vaccine efficacy was measured with a fouritem scale with .90 (e.g., This vaccine is effective in
preventing cervical cancer, and This vaccine would greatly
reduce the chance of getting cervical cancer). Perceived vulnerability was measured with a four-item scale with .70
(e.g., My daughter will get cervical cancer at sometime in her
life, and It is very unlikely that my daughter will get infected
with the HPV virus (R). Perceived obstacles to vaccination
were measured via a four-item scale with .89 (e.g., I
would find it hard to find the time to take my daughter to get the
shots, and It would be hard to get the transportation to take
my daughter to get the shots).
Perceived message comprehension was measured with a
summed four-item Likert scale with .85, taken from Cox,
Cox, and Zimet (2006; e.g., The message was easy to understand, and This message was useful to me). The Need for
Internal Consistency scale (Cialdini et al., 1995) consists of nine
statements that use a Likert-type response scale (e.g., It is important to me that I can predict what I do, and I want to be described
as stable and predictable; .87). Numeracy was assessed as the
total number of correct responses to Schwartz et al.s (1997)
three-question scale of numerical fluency. Finally, participants
provided demographic information (e.g., race, age, and education)
and were asked about prior awareness of the HPV vaccine,
whether they or any female relative had ever been diagnosed with
cervical cancer, and their perceptions of whether their daughter
had engaged in sexual activity.

Statistical Analysis Methods

The baseline demographic characteristics of the six experimental groups were compared by using Pearson chi-square tests for
categorical variables and one-way ANOVA for continuous variables (daughters age). A significance level of .05 was used to
assess significance.
The main and interactive effects of the experimental interventions on the outcome variables were assessed by using an
ANOVA. Where significant interactions were found, the simple
effects of one factor within levels of the other factor were analyzed
per Keppel (1982, pp. 214 219). Tests of mediation were performed by using Baron and Kennys (1986) method (estimating a
series of regression models and testing the significance of the
unstandardized regression coefficients) as well as the Sobel (1982)
test. All analyses were performed using SPSS version 14.0 (SPSS,
Chicago, IL).

COX, COX, STURM, AND ZIMET

34

Figure 1. Examples of risk presentation formats (graphic vs. nongraphic). The stadium graphic is shown here
in gray scale; the actual stadium graphic viewed by participants used a red background for 87,000 get cancer
and a green background for 60,000 saved.

Results
Effects of Interventions on Reported
Message Comprehension
We predicted that those viewing the graphic depiction of the
HPV statistics would report higher message comprehension than
those in the nongraphic or control groups. To test this hypothesis,
an ANOVA was conducted with perceived message comprehension as the dependent variable and risk presentation format and
rhetorical question as independent variables. Respondents demographic traits (e.g., age, race, and education), personal and family
history of cervical cancer, and perceptions regarding their daughters sexual activity were all evaluated as potential covariates.
However, none of these background variables correlated signifi-

cantly ( p .05) with either reported message comprehension or

vaccination intention. Thus, no covariates were included in the
analysis.
The reported message comprehension mean for the graphicpresentation condition (M 23.70) is higher than that for both
the nongraphic presentation (M 22.83) and the control (M
22.82), but these differences are not significantly different at
p .05, F(2, 465) 2.65, p .072. However, there is a
significant interactive effect of risk presentation and rhetorical
question on perceived message comprehension, F(2, 465)
3.80, p .023, measure of effect size 2 .016. Please see
Figure 2 for this interactive effect.
To understand this interaction better, we analyzed the simple
effects of the risk presentation within each of the two RQ condi-

INTERVENTIONS TO INCREASE HPV VACCINATION

35

Estimated Marginal Means

24.50

24.00

23.50

p = .06

ns
p = .006

23.00

22.50

nograph
graph

no statistics
22.00

yes

no

Rhetorical Question (RQ)

Figure 2.

Effects of risk presentation format and RQ on message comprehension.

tions (Keppel, 1982, pp. 214 219). This analysis revealed that
when the rhetorical questions are asked, there is no significant
difference between the risk presentation formats on perceived
message comprehension. However, when the rhetorical questions
are not asked, the graphic presentation results in higher reported
message comprehension (M 24.20) than in the no-graph condition (M 22.66) and the control condition (M 22.03). A post
hoc Bonferroni test revealed that the graphic condition was significantly different from the control condition ( p .006) and
approached a significant difference from the no-graph condition
( p .06). This interaction demonstrates that asking the rhetorical
questions moderates the effect of risk presentation on perceived
message comprehension, so that when RQ is not asked, the graphic
risk presentation condition elicits the highest level of reported
message comprehension.

Effects of Interventions on Vaccination Intention

We also expected main effects of both the RQ and the risk
presentation on mothers intention to have their daughter receive the HPV vaccination. To test this, an ANOVA was
conducted with the three-item total shot intention scale as the
dependent variable. This analysis revealed a significant main
effect of risk presentation on total shot intention, F(2, 465)
5.68, p .004, 2 .024, with the graphic presentation
producing significantly higher mean vaccination intentions
(M 12.96) than did either the nongraphic (M 11.89) or
no-statistics control (M 11.88) conditions. Examining categorical responses, we found that 53% of mothers in the graphic
condition stated that their daughters would definitely get at

least one HPV vaccine dose, in comparison with 41% in the

nongraphic condition and 37% in the control group. A post hoc
Bonferroni test revealed that the mean intention in the graphic
condition was significantly higher than was either the no-graph
( p .01) and the control ( p .01) conditions.
There was also a significant main effect of RQ on HPV vaccination
intention, F(1, 465) 4.55, p .033, 2 .01. Mothers who were
asked the RQ reported significantly stronger intentions to have their
daughters get the HPV vaccine (M 12.60; with 48% saying definitely will get at least one dose) than did those who were not asked
the RQ (M 11.9, 39% definitely). However, the main effects of both
risk presentation and RQ should be interpreted with some caution,
because there is also a significant interactive effect between RQ and
risk presentation format on total shot intention, F(2, 465) 3.37, p
.035, 2 .014. As can be seen in Figure 3, the graphic presentation
appears to produce higher total shot intentions than does the nongraphic presentation, regardless of whether the RQ is asked. However,
Figure 3 also suggests that the effect of RQ on total shot intention
varies markedly among the three risk-information groups. In the two
conditions in which mothers were given statistical risk information
(graphic or nongraphic), asking RQ had little effect on total shot
intention. However, among participants in the no-statistics control
condition, asking rhetorical questions had a strong effect, with participants in the RQ condition expressing significantly higher total shot
intentions (M 12.77) than did participants in the no-RQ condition
(M 11.04), F(1, 147) 10.17, p .002, 2 .065. This suggests
that the presentation of numerical risk information (whether accompanied by a graph or not) somehow diminishes or disrupts the effect
of the rhetorical question on mothers total shot intentions.

COX, COX, STURM, AND ZIMET

36

Estimated Marginal Means

13.50

13.00

12.50

p = .034
ns

12.00

p = .004

11.50

ns

No-graph
graph
11.00

control
yes

no

Rhetorical Question (RQ)

Figure 3.

Effect of risk presentation and RQ on total shot intentions.

Mediation Analyses
We expected that the effects of risk presentation and RQ on
vaccination intention might be mediated by respondents health
beliefs, including perceptions of their daughters vulnerability to
HPV infection, severity of HPV infection, vaccine efficacy, and
pragmatic obstacles to vaccination. To identify potential mediators, we conducted a series of ANOVAs, examining the effect of
the two independent variables on each of the four possible mediators. These analyses revealed that risk presentation affected only
one health belief, vaccine efficacy, F(2, 468) 4.3, p .014,
while rhetorical question affected two: perceived severity of HPV
infection, F(1, 469) 8.1, p .005, and perceived pragmatic
obstacles to vaccination, F(1, 469) 5.32, p .021.
Next, we conducted mediation analyses to determine (a)
whether perceived vaccine efficacy mediates the effects of risk
presentation on total shot intention and (b) whether perceived HPV
severity and pragmatic obstacles mediate the effects of RQ on total
shot intention. We used Baron and Kennys (1986) mediation test
method, estimating a series of regression models and testing the
significance of the (unstandardized) regression coefficients.
Tests of mediation for risk-presentation effects. First, we
examined whether perceived vaccine efficacy mediated the effect
of risk presentation on total shot intention. Because risk presentation has three levels, two dummy variables were created for this
analysis: one comparing the graphic condition to the no-statistics
control (graphdum) and the other comparing the nongraphic condition to the control (statdum). Following Baron and Kenny
(1986), we first regressed total shot intention on each of the
risk-presentation dummy variables. Results indicate that graphdum

is a significant predictor of total shot intention (B 1.075, t

3.426, p .001), while statdum was not. Next, we regressed total
shot intention simultaneously on both graphdum and vaccine efficacy. In this case, the impact of graphdum on total shot intention
remained significant, even when vaccine efficacy was included as
a predictor. Therefore, vaccine efficacy does not mediate the effect
of graphic presentation on total shot intention.
Tests of mediation for rhetorical-question effects. First, bivariate regression models confirmed that RQ had a significant
impact on perceived HPV severity (B 1.30, t 2.85, p
.005, r2 .017; if RQ asked, higher perceived severity) and
pragmatic obstacles (B 1.018, t 2.307, p .021, r2
.011; if RQ asked, higher perceived obstacles). Second, a bivariate
regression model confirmed that RQ had a significant effect on
total shot intention (B .676, t 2.24, p .025, r2 .011).
Third, we regressed total shot intention simultaneously on both (a)
perceived severity and (b) RQ. This analysis revealed that the
proposed mediator (perceived severity) had a significant effect on
total shot intention (B .112, t 3.82, p .000, partial r2
.030), whereas the effect of the independent variable (RQ) became
nonsignificant (B .526, t 1.756, p .08, partial r2
.006). In addition, Sobels (1982) test confirmed the statistical
significance of the indirect effect of rhetorical question on intention, mediated by perceived severity (z 2.29, p .022). When
these same analyses were conducted with the proposed mediator,
pragmatic obstacles, there was no evidence of mediation. Thus
only one factor, perceived HPV severity, appears to mediate the
effect of rhetorical question on vaccination intention (RQ3 increased perceived HPV severity3 increased total shot intentions).

INTERVENTIONS TO INCREASE HPV VACCINATION

Analysis of Potential Moderators: Numeracy and Need

for Consistency
To test for the moderating effect of numeracy, we entered each
of the three numeracy scale items into a separate ANOVA, along
with risk presentation format, to determine its main and interactive
effects on reported message comprehension and total shot intention. Education was a significant correlate of each of the numeracy
items (r .118, r .136, and r .127, respectively) and was
included as a covariate in the three analyses. These analyses found
no main or interactive effects (at p 05) of any of the three
numeracy items on either shot intention or reported message
comprehension.
To test for the moderating effect of need for consistency, a
median split was conducted on this scale. Next, an ANOVA was
conducted, with this dichotomous scale and RQ as independent
variables, and total shot intention as the dependent variable. Results revealed that there was no significant interaction between RQ
and need for internal consistency ( p 05), but need for internal
consistency had a main effect on total shot intention, F(1, 467)
5.94, p .015, 2 .013. Mothers with a high need for consistency had significantly stronger intentions to vaccinate their
daughters (M 12.63) than did mothers with a low need for
consistency (M 11.86).

Discussion
Routine HPV vaccination of adolescent and preadolescent girls
has the potential to greatly reduce the incidence of cervical cancer,
especially in minority and disadvantaged communities, where access to regular Pap screening is less common. However, childhood
HPV vaccination, unlike other ACIP-recommended vaccinations,
is not mandated for school entry in most states, and this is unlikely
to change in the foreseeable future, given the political backlash
against previous mandate attempts. Therefore, the potential public
health benefits of childhood HPV vaccination will only be realized
if a large percentage of parents decide voluntarily to have their
daughters vaccinated.
This study examined two message interventions designed to
help achieve this goal. First, we examined the impact of a graphic
depiction of cervical cancer risk and HPV vaccine efficacy on
parents self-reported understanding of these risks and benefits,
and their intentions to have their daughters vaccinated. Past research suggests that lay people often find traditional riskcommunication methods (using either numerical probabilities or
verbal descriptors such as rare or common) confusing and
ambiguous, but that graphic risk depictions may facilitate message
understanding and acceptance. Second, we examined the impact of
an attitude-elicitation method called rhetorical question on parents intention to have their daughters vaccinated against HPV
infection. The effects of these two interventions were tested in a
factorial experiment, in which a national sample of parents with
young daughters was randomly assigned to different message
conditions and then asked to report their beliefs, attitudes and
intentions regarding HPV, cervical cancer, and the HPV vaccine.
As was hypothesized, parents who viewed a graphic presentation of HPV vaccinations risk-reduction benefits reported significantly stronger intentions to have their daughters vaccinated, in
comparison both with parents who viewed a nongraphic presenta-

37

tion of this risk information and with parents who saw no risk
statistics at all. As was also hypothesized, parents who answered
rhetorical questions about protecting their daughters from cancer
later expressed significantly stronger intentions to vaccinate their
daughter against HPV infection than did parents who had not been
asked these rhetorical questions.
However, there were also several interesting interactions between graphic presentation and rhetorical question. These interactions reveal a recurring pattern, in which the two interventions
seem to dampen each others effect; that is, each intervention
seems to be most effective in the absence of the other. For
example, we had hypothesized that graphic presentation of risk
information would enhance respondents reported message comprehension. However, the main effect of graph on reported comprehension, while in the predicted direction, was not statistically
significant. Instead, there was the significant interaction between
graph and rhetorical question depicted in Figure 2. Among parents
not asked the rhetorical questions, graphic risk presentation had the
hypothesized effect, significantly enhancing reported message
comprehension in relation to both nongraphic statistics and the
no-statistics control. However, among parents first asked the rhetorical question, this effect essentially disappeared.
Similarly, the graphic and rhetorical question interventions appear to dampen each others impact on parents vaccination intentions. For example, Figure 3 reveals that while rhetorical question
had a strong positive effect on the vaccination intentions of parents
who did not view any risk-statistics information (graphic or nongraphic), this intervention had no effect on the vaccination intentions of parents who viewed either form of risk-statistics information. In interpreting these findings, it is interesting to note that
among parents not viewing risk statistics, agreeing with the rhetorical question essentially initiates an uninterrupted syllogism,
pointing to the logical conclusion that ones daughter should
receive the HPV vaccine:
1.

Major premise (rhetorical question): If there was a vaccine to protect my daughter against cancer, I would have
her get it.

2.

Minor premise (baseline HPV information given to all

participants): Girls who get this [HPV] vaccine now are
much less likely to get cervical cancer later in life.

3.

Conclusion (intention question): [Therefore] I will have

my daughter get the HPV vaccine.

However, for parents in the two statistical conditions (graphic or

nongraphic), this logical sequence is interrupted after Step 2, when
participants are asked to process fairly detailed quantitative risk
information. This interruption appears to have disrupted the rhetorical (or persuasive) effect of the rhetorical questions on parents vaccination intentions.
Similar effects can be seen in examining the interventions
impact on parents beliefs concerning HPV infection and vaccination. As was noted earlier, rhetorical question had a main effect on
perceived severity, strengthening parents belief that HPV is a
serious disease (and especially their belief that HPV causes cancer). However, this effect was significantly moderated by risk
presentation: Again, among parents who did not see risk statistics

38

COX, COX, STURM, AND ZIMET

(graphic or nongraphic), RQ had an extremely strong effect on

perceived HPV severity (2 .13). However, among parents
exposed to either type of risk statistics, RQ had no effect. Along
the same lines, while graphic risk presentation had a positive main
effect on parents perceptions of vaccine efficacy, this effect was
much stronger among parents who were not asked the RQ (2
.036) than among those who were (2 .004). Together, these
findings suggest that rhetorical question and graphic presentation
work through quite different, and perhaps conflicting, persuasive
mechanisms. Thus, while each of these interventions had an overall positive effect on parents intention to vaccinate their daughters, they appear to be more effective when used separately than
when used in combination.
As with all research, this study has limitations that should be
addressed in future research. First, the principal dependent variable
in this study was parents intention to vaccinate their children
rather than actual vaccination behavior. Future research should
examine the effectiveness of these interventions in a clinical setting, using actual vaccination behavior as the outcome measure.
The interventions examined in this study show promise for clinical
application: Both are quite brief and might easily be integrated into
questionnaires that are increasingly administered in clinical settings. However, before these interventions are widely implemented, their behavioral efficacy should be confirmed in a randomized clinical trial. Second, while an ever-growing share of
Americans now have Internet access (including an estimated 50
60% in low-SES and minority communities; see Kind, Huang,
Farr, & Pomerants, 2005) and our Internet sample intentionally
oversampled less-educated and minority populations, future studies should expand this research to populations without Internet
access. Third, while the present study offered some insights into
the mechanisms through which the interventions work, more research is needed in this area. Specifically, a number of studies have
now found that graphic displays enhance the effectiveness of risk
presentations; however, the exact mechanism through which this
effect occurs is still not entirely clear. In this study, we found that
graphic display had positive effects on both self-reported message
comprehension and perceived efficacy; however, neither of these
variables fully mediated the persuasive impact of graphics. Future
researchers should both examine these two mediators in greater
depth (e.g., by including objective measures of message comprehension, such as speed and accuracy of message recall) and examine a broader range of potential mediators, to help us better
understand how graphics may aid medical decision making. Finally, this study focused on one specific health phenomenon,
parents intentions to vaccinate their daughters against HPV infection. Future research should examine the potential efficacy of these
interventions in other health contexts.
Cervical cancer takes thousands of lives each year, taking a
particularly heavy toll within disadvantaged communities. HPV
vaccination has the potential to greatly reduce the incidence of this
costly disease. However, such potential will only be realized if
clinicians and health communicators are able to effectively communicate the vaccines benefits and risks to parents and if large
numbers of these parents choose voluntarily to have their daughters vaccinated. In this article, we have presented two message
interventions that may aid such communication and presented
encouraging evidence of their potential effectiveness in increasing
parents intentions to protect their daughters from HPV infection

through early vaccination. We hope that future research will continue to examine the potential of these interventions, in the context
of both HPV vaccination and other important health-protective
behaviors.

References
Baron, R. M., & Kenny, D. A. (1986). The moderatormediator variable
distinction in social psychological research: Conceptual, strategic, and
statistical considerations. Journal of Personality and Social Psychology,
51, 11731182.
Becker, M. H. (Ed.). (1974). The health belief model and personal health
behavior [Special Issue]. Health Education Monographs, 2.
Berry, D. (2004). Risk communication and public health. New York: Open
University.
Bonnefon, J. F., & Villejoubert, G. (2006). Tactful or doubtful? Expectations of politeness explain the severity bias in the interpretation of
probability phrases. Psychological Science, 17, 747751.
Centers for Disease Control and Prevention. (2007). Quadrivalent human
papillomavirus vaccine: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). Morbidity & Mortality Weekly Reports, 56(No. RR-2).
Chua, H. F., Yates, J. F., & Shah, P. (2006). Risk avoidance: Graphs vs.
numbers. Memory & Cognition, 34, 399 410.
Cialdini, R. B. (1988). Influence: Science and practice. Boston: Scott
Foresman.
Cialdini, R. B., Trost, M. R., & Newsom, J. T. (1995). Preference for
consistency: The development of a valid measure and discovery of
surprising behavioral implications. Journal of Personality and Social
Psychology, 69, 318 328.
Cox, A., Cox, D., & Zimet, G. (2006). Understanding consumer responses
to product risk information. Journal of Marketing, 70, 70 91.
Cox, D., & Cox, A. (2001). Communicating the consequences of early
detection: The role of evidence and framing. Journal of Marketing, 65,
91103.
Cox, D., & Cox, A. (2007, June). Consumers interpretation of risk
language in Rx drug advertising. Paper presented at Marketing and
Public Policy Conference, Washington, D.C.
Davis, K., Dickman. E. D., Ferris, D., & Dias, J. K. (2004). Human
papillomavirus vaccine acceptability among parents of 10- to 15-yearold adolescents. Journal of Lower Genital Tract Disease, 8, 188 194.
Dempsey, A. F., Zimet, G. D., Davis, R. L., & Koutsky, L. (2006). Factors
that are associated with parental acceptance of human papillomavirus
vaccines: A randomized intervention study of written information about
HPV. Pediatrics, 117, 1486 1493.
Dolin, D., & Booth-Butterfield, S. (1995). Cancer prevention and the
foot-in-the-door technique. Health Communication, 7, 55 66.
Edwards, A., Elwyn, G., & Gwyn, R. (1999). General practice registrant
responses to the use of different risk communication tools in simulated
consultations: A focus group study. British Medical Journal, 319, 749
752.
Elbasha, E. H., Dasback, E. J., & Insinga, R. P. (2007). Model for assessing
human papillomavirus vaccination strategies. Emerging Infectious Diseases, 13, 28 41.
Ferris, D., Waller, J., Owen, A., & Smith, J. (2008). HPV vaccine acceptance among mid-adult women. Journal of the American Board of
Family Medicine, 21, 3137.
Fraser, C., Tomassini, J. E., Liwen, X., Golm, G., Watson, M., Giuliano,
A. R., et al. (2007). Modeling the long-term antibody response of a
human papillomavirus (HPV) virus-like particle (VLP) type 16 prophylactic vaccine. Vaccine, 25, 4324 4333.
Freedman, J. L., & Fraser, S. C. (1966). Compliance without pressure: The
foot-in-the-door technique. Journal of Personality and Social Psychology, 4, 196 202.

INTERVENTIONS TO INCREASE HPV VACCINATION

Gerend, M. A., Lee, S., & Shepherd, J. E. (2007). Predictors of human
papillomavirus vaccination among underserved women. Sexually Transmitted Diseases, 34, 468 471.
Gerend, M. A., & Shepherd, J. E. (2007). Using message framing to
promote acceptance of the human papillomavirus vaccine. Health Psychology, 26, 745752.
Huerta, E. (2003). Cancer statistics for Hispanics, 2003: Good news, bad
news, and the need for a health system paradigm change. CA: A Cancer
Journal for Clinicians, 53, 205207.
International Agency for Research on Cancer [IARC]. (1995). Human
papillomaviruses. Monographs on the Evaluation of Carcinogenic Risks
to Humans, 64.
Jamieson, L., & Bass, F. (1989). Adjusting stated intention measures to
predict trial purchase of new products: A comparison of models and
methods. Journal of Marketing Research, 26, 336 345.
Keppel, G. (1982). Design and analysis: A researchers handbook. Englewood Cliffs, NJ: Regents/Prentice Hall.
Kim, J. J., & Goldie, S. J. (2008). Health and economic implications of
HPV vaccination in the United States. New England Journal of Medicine, 359, 821 832.
Kind, T., Huang, Z. J., Farr, D., & Pomerants, K. L. (2005). Internet and
computer access and use for health information in an underserved
community. Ambulatory Pediatrics, 5, 117121.
Kulasingam, S. L., Myers, E. R., Lawson, H. W., McConnell, K. J.,
Kerlikowske, K., Melnikow, J., et al. (2006). Cost-effectiveness of
extending cervical cancer screening intervals among women with prior
normal pap tests. Obstetrics and Gynecology, 107, 321328.
Kuper, H., Adams, H. O., & Trichopoulos, D. (2000). Infections as a major
preventable cause of human cancer. Journal of Internal Medicine, 248,
171183.
Leader, A. E., Weiner, J. L., Kelly, B. J., Hornik, R. C., & Cappella, J. N.
(2009). Effects of information framing on human papillomavirus vaccination. Journal of Womens Health, 18, 225233.
Lipkus, I. M., & Hollands, J. G. (1999). The visual communication of risk.
Journal of the National Cancer Institute Monograph, 25, 149 163.
National Cancer Institute [NCI]. (n.d.-a). NCI factsheet: Human papillomavirus and cancer: Questions and answers. Retrieved August 4, 2008,
from http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
National Cancer Institute [NCI]. (n.d.-b). Surveillance epidemiology and
end results (SEER). Retrieved August 4, 2008, from http://seer.cancer
.gov/faststats/selections.php#output
Olshen, E., Woods, E. R., Austin, S. B., Luskin, M. L., & Bauchner, H.
(2005). Parental acceptance of HPV vaccination. Journal of Adolescent
Health, 37, 249 251.
Olsson, S., Villa, L. L., Costa, R. L., Petta, C. A., Andrade, R. P., Malm,
C., et al. (2007). Induction of immune memory following administration

39

of a prophylactic quadrivalent human papillomavirus (HPV) types 6/11/

16/18 L1 virus-like particle (VLP) vaccine. Vaccine, 25, 4931 4939.
OBrien, K., Cokkinides, V., Jemal, A., Cardinez, C., Murray, T., Samuels,
A., et al. (2003). Cancer statistics for Hispanics, 2003. CA: The Cancer
Journal for Clinicians, 53, 208 226.
Paivio, A. (1971). Imagery and verbal processes. New York: Holt, Rinehart and Winston.
Rosenstock, I. M. (1966). Why people use health service. Milbank Memorial Fund Quarterly, 44, 94 124.
Sanders, G. D., & Taira, A. V. (2003). Cost-effectiveness of a potential
vaccine for human papillomavirus. Emerging Infectious Disease, 9,
37 48.
Schwartz, L. M., Woloshin, S., Black, W. C., & Welch, H. G. (1997). The
role of numeracy in understanding the benefit of screening mammography. Annals of Internal Medicine, 127, 966 972.
Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in
structural equation models. Sociological Methodology, 13, 290 312.
Stone, E. R., Yates, J. F., & Parker, A. M. (1997). Effects of numerical and
graphical displays on professed risk-taking behavior. Journal of Experimental Psychology Applications, 3, 243256.
Sturm, L. A., Mays, R. M., & Zimet, G. D. (2005). Parental beliefs and
decision making about child and adolescent immunization: From polio
to sexually transmitted infections. Developmental and Behavioral Pediatrics, 26, 441 452.
Tversky, A., & Kahneman, D. (1981). The framing of decisions and the
psychology of choice. Science, 211, 453 458.
Villa, L. L., Costa, R. L., Petta, C. A., Andrade, R. P., Paavonen, J.,
Iversen, O. E., et al. (2006). High sustained efficacy of a prophylactic
quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up. British Journal of Cancer, 95,
1459 1466.
Villa, L. L., Perez, G., Kjaer, S. K., Paavonen, J., Lehtinen, M., Munoz, N.,
et al. (2007). Quadrivalent vaccine against human papillomavirus to
prevent high-grade cervical lesions, New England Journal of Medicine,
356(19), 19151927.
Wallace, C., Leask, J., & Trevena, L. J. (2006). Effects of a web-based
decision aid on parental attitudes to MMR vaccination: A before and
after study. British Medical Journal, 24, 539 547.
Waters, E., Weinstein, N. D., Colditz, G. A., & Emmons, K. (2006).
Formats for improving risk communication in medical tradeoff decisions. Journal of Health Communication, 11, 167182.
Zimet, G. D. (2005). Improving adolescent health: Focus on HPV vaccine
acceptance. Journal of Adolescent Health, 37, s17s23.
Zimet, G. D., Shew, M. L., & Kahn, J. A. (2008). Appropriate use of
cervical cancer vaccine. Annual Review of Medicine, 599, 223236.