Elsevier

Vaccine

Volume 34, Issue 41, 22 September 2016, Pages 4985-4990
Vaccine

Modification and validation of the Treatment Self Regulation Questionnaire to assess parental motivation for HPV vaccination of adolescents

https://doi.org/10.1016/j.vaccine.2016.08.037Get rights and content

Highlights

  • Lack of motivation measures impedes its application to HPV vaccine decision-making.

  • The current study adapted the TSRQ to measure motivation for HPV vaccination.

  • Analyses provide evidence for the validity of the TSRQ in this context.

Abstract

Background

According to Self-Determination Theory, the extent to which the motivation underlying behavior is self-determined or controlled influences its sustainability. This is particularly relevant for behaviors that must be repeated, such as completion of the human papillomavirus (HPV) vaccine series. To date, no measures of motivation for HPV vaccination have been developed.

Methods

As part of a larger study, parents (N = 223) whose adolescents receive care at safety-net clinics completed a telephone questionnaire about HPV and the vaccine. We modified the Treatment Self-Regulation Questionnaire to assess parents’ motivation for HPV vaccination in both Spanish and English. We used confirmatory factor analysis to test a three-factor measurement model.

Results

The three-factor model fit the data well (RMSEA = 0.04, CFI = 0.98, TLI = 0.96), and the scales’ reliabilities were adequate (autonomous: α = 0.87; introjected: α = 0.72; external: α = 0.72). The factor loading strength for one item was stronger for Spanish- than English-speaking participants (p < 0.05); all others were equivalent. The intercorrelations among the scales ranged from −0.17 to 0.32, suggesting discriminant factors. The scales displayed the expected pattern of correlations with other psychosocial determinants of behavior. Vaccination intentions showed a strong correlation with autonomous motivation (r = 0.52), but no correlation with external motivation (r = 0.02), suggesting autonomous motivation may be particularly important in vaccine decision-making.

Conclusion

Findings support the use of three subscales to measure motivation in HPV vaccination and suggest possible cultural differences in motivation.

Introduction

Motivation is a key determinant for initiation and maintenance of health behaviors [1], [2] but has not been examined in HPV vaccination. According to Self-Determination Theory (SDT), motivation occurs along a continuum ranging from self-determined (performed for internal reasons) to controlled (performed due to external pressures) to amotivation (the absence of motivation). Behaviors are more likely to be maintained if the behavior is autonomously motivated [3]. Since 2007 guidelines recommending routine administration of the 3-dose HPV vaccine series to adolescent girls aged 11–12 (boys added in 2011), national data shows suboptimal vaccine uptake [4]. Parents, the primary decision-makers, are often hesitant and delay vaccination for a number of reasons [5], [6]. Theoretically, facilitating autonomous motivation in parents should improve HPV vaccine initiation and completion. However, the lack of valid motivation measures impedes its application to HPV vaccine decision-making.

Autonomously motivated behaviors are those for which people experience a true sense of volition and are performed because of a personal sense of the behavior’s importance [7]. Autonomous motivation facilitates behaviors that are in line with a person’s values and have been integrated into the person’s sense of self. There are two forms of ‘controlled’ motivation: behaviors performed to avoid feeling guilty (introjected motivation), and behaviors performed for a reward or to avoid a negative consequence (external motivation). Practically speaking, an autonomously motivated parent decides to vaccinate their child because they believe in its value and benefit, whereas a parent operating under controlled motivation decides to vaccinate their child to meet others’ expectations (e.g., their child’s doctor). For the 3-dose HPV vaccine series, autonomous motivation may be important in influencing two aspects of parental decisions: (1) timing of the first dose - initiating at the recommended ages (11–12) versus later in adolescence, and (2) timely completion - obtaining the second and third doses on-schedule (i.e., 2 and 6 months after the first dose). Psychometrically sound measures of parental motivation for HPV vaccination are needed in order to examine if it is a determinant of vaccine initiation and series completion and the pathways linking it to other theory-based determinants (e.g., intention, subjective norms).

Validated across a wide range of behaviors [8], the original Treatment Self-Regulation Questionnaire (TSRQ) includes items assessing the different types of motivation, but has only been evaluated in English-speaking populations. A valid Spanish TSRQ HPV vaccine version is needed because many patients in U.S. safety-net healthcare settings prefer to communicate in Spanish and they are at high risk for HPV-related cancers.

This study adapted and gathered evidence on the validity of a TSRQ measuring autonomous, introjected, and external motivation with English- and Spanish-speaking parents. We excluded amotivation items because previous studies demonstrated poor factor loadings compared to items measuring the other motivation types [8]. We assessed construct validity in two ways. First, we examined the scale’s factor structure and tested for factorial equivalence by language. Evidence of factorial invariance is necessary to assess potential group differences in motivation (past studies have shown the influence of other HPV vaccine determinants vary by race/ethnicity and language [9]). Second, we tested discriminant validity. Based on SDT, we hypothesized that factors closer along the continuum of self-determination would show stronger correlations with each other than those factors that are farther apart (e.g., autonomous motivation should correlate more strongly with introjected motivation than with controlled motivation). We also hypothesized that the magnitude of the correlations between the three motivation subscales and other determinants (self-efficacy, perceived benefits, intentions, and subjective norms) would differ. Specifically, (a) autonomous motivation would have stronger, positive correlations with self-efficacy, perceived benefits, and intentions than with subjective norms; (b) the magnitude of the correlations between introjected motivation and the other determinants would be weaker than for autonomous motivation and stronger than those shown with external motivation; and (c) external motivation would have stronger correlations with subjective norms than with self-efficacy, perceived benefits, and intentions.

Section snippets

Methods

This study was part of a multi-stage project to develop, refine, and test a tablet-based self-persuasion intervention to promote HPV vaccination among parents who are undecided about the vaccine (for additional details, see [10]). The analyses reported here used baseline survey data from the first stage of the project that characterized parents’ thoughts and reasons for the HPV vaccine and patient-provider HPV vaccine discussions.

Analysis

Of the 223 parents in the dataset, 215 (96.4%) had complete responses on the motivation items. Analyses were limited to these parents to allow for the examination of modification indices and best estimates of model fit.

Results

Characteristics of parent/guardian respondents stratified by language are in Table 1. The majority of the sample was Spanish-speaking (59.6%), Hispanic Whites (64.1%). Most participants were women (99.5%) with ages ranging from 22 to 75 (M = 39.8). Spanish- and English speakers differed on education, with English speakers reporting higher levels of education (χ2 = 0.435, p < 0.05). In terms of adolescent sex, the sample was evenly split (52.5% of parents answered questions for their son). There were

Discussion

The findings support the validity of the TSRQ as a measure to assess motivation to engage in HPV vaccination. CFAs replicated the underlying factor structure of the TSRQ demonstrated in previous work [8] across two different language groups. Results of the factorial invariance analyses support an equivalent structure across Spanish- and English-speaking populations. Only one item (“…because you want to take responsibility for your child’s health”) had a stronger factor loading for Spanish- than

Conflict of interest

All authors declare no conflict of interest.

Acknowledgements

All phases of this study were supported by a National Institutes of Health grant (PIs: Tiro, Baldwin; 1R01CA178414). Supplementary support was provided to Deanna Denman by a supplement to the parent grant (Denman; 3R01CA178414-02S1). Additional support provided by the UTSW Center for Translational Medicine, through the NIH/National Center for Advancing Translational Sciences (UL1TR001105), the Harold C. Simmons Cancer Center (1P30 CA142543), and the UT Southwestern Center for Patient-Centered

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