Table of Contents
Problem Statement
Health promotion campaigns utilize risk-perception research in order to determine how to best construct key messages in the delivery of information to health consumers. Cancer-related risk-perception research has been extended to vaccination-based risk perception research with the introduction of the HPV (Human papillomavirus) vaccine to protect against cervical cancer. HPV is the most prevalent sexually transmitted infection (STI) in the United States with an estimated 25% of women infected. Women ages 20-24 have the highest rates of infection at 45%. HPV types 16 and 18 are responsible for over 70% of all cervical cancers while HPV types 6 and 11 cause over 90% of all cases of genital warts (Vanderpool, R. C., Casey, B. R., & Crosby, R. A., 2011).
HPV can cause other diseases such as cancers of the throat, anus, vulva and vagina (Merck & Co., Inc, 2011). An estimated 20 million individuals become infected annually with cervical cancer being the cause of death for roughly 4,000 U.S. women per year (Park, S.Y., 2012). Administered in a three-part series, the vaccine demonstrates close to 100% efficacy in preventing precancerous cervical cellular growths (Vanderpool, 2011). The vaccine is recommended for girls ages 9-12, and is approved through age 26 as the “catch up” group. The vaccine, has also been approved for males, although it is not included in the routine immunization schedule (Dunne, E. F., Sternberg, M., Markowitz, L. E., McQuillan, G., Swan, D., Patel, S., & Unger, E. R., 2011).
The National Health and Nutrition Examination Surveys (NHANES) have provided data regarding the prevalence of HPV types 6, 11, 16, and 18, the types which the most common HPV vaccine, Gardasil, protects against. Several demographic variables were found to be associated with HPV infection. Associated factors were being in age group 18-19, education less than high school, marital status (living with partner), sexual behavior having had more than six lifetime partners, recent multiple partners, and ever having had genital warts (Dunne, 2011). Multi-million dollar campaigns have been implemented to promote HPV vaccination. In spite of this, the 2008 Behavioral Risk Factor Surveillance System data indicated only 34.4% of girls ages 13-17 were vaccinated (Park, 2012).
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According to the 2008 National Health Information Survey, only 11% of young women ages 19-26 have been vaccinated and a mere 6% have completed the three-part HPV vaccination series (Schiller, J., 2009). The CDC found that less than 20% of adolescent girls had completed the three-injection series in 2008. Common barriers to vaccination include cost, fears about the safety of the vaccine and general lack of knowledge about the vaccine itself (Park, 2012). Given the high prevalence of this STI, it is critical for public health professionals to understand HPV risk-related perceptions surrounding the vaccine and to demonstrate more effective marketing strategies that address these perceptions rather than undifferentiated mass media campaigns.
S.M.A.R.T. Objectives
The CDC recommends the vaccination for young adults through age 26. The primary focus of pharmaceutical marketing campaigns has been children ages 9-12. Hence, the “catch up” pool consists of youth ages 13-26. Many young women over the age of 18 may be uninsured and may no longer qualify for childhood vaccination programs, thus this population of women are an important target for public health campaigns (Vanderpool, 2011).
The strategic objective of the HPV vaccination mass media campaign is to increase vaccine uptake and vaccine completion rate by the target population to a rate of 40% within three years of campaign initiation. The baseline vaccination measures for the campaign are based on data from the 2008 NHIS which indicated only 11% of women ages 19-26 had received one HPV vaccination while only 6% had completed the full three doses (Schiller, 2009). Partners and stakeholders agree the goals and objectives of the campaign are attainable within the time frame. The goals of the campaign are relevant to improving health and reducing health inequalities in the target population. The time frame of the media campaign activities will be extended over one year with rates of vaccination expected to increase by roughly 30% over the course of three years.
Three Segments of the Target Population
In addition to providing baseline vaccination rates, data from the 2008 NHIS revealed levels of vaccination were highest among non-Hispanic Whites (13%) followed by non-Hispanic blacks (7%). Lowest levels of vaccination were among Hispanics (6%). Despite high levels of awareness of the disease and the vaccine, rates of HPV vaccination remain low. The study also noted women of higher socioeconomic status were more likely to be vaccinated than women in lower socioeconomic status’ (Schiller, 2009). These data helped to refine the three segments of the target population selected for this mass media campaign. Rather than focusing on specific ethnic groups as target segments, the campaign will target three “occupational” groups. In order to reach groups which demonstrate lower levels of vaccination, print media and advertising will be strategically situated in accessible community locations.
The first segment of the target population will seek to reach the college-aged woman 18-26 years of age. We chose this segment because college students are a population in which STIs are prevalent. The HPV vaccine is recommended for this group (Park, 2012). The second segment the campaign will target is young mothers ages 18-26. This group of women is likely to come into contact with healthcare professionals given the various pediatric medical needs of their children. The final segment chosen for the campaign is young working women ages 18-26. These women may or may not have health insurance coverage and the campaign is aimed at reducing the barrier of cost not only for the HPV vaccine but also for cervical cancer screening.
Message and Key Promise for Each Segment
Health behavior theories such as the Health Belief Model can help us to understand consumer’s perceptions of susceptibility to the disease, perceptions of severity of HPV, barriers versus benefits, and perceived risks of the vaccination. A notable study found that HPV vaccine acceptability was higher among women who perceived greater likelihood of contracting the disease, believed the vaccine to be effective, and believed their doctor would recommend the vaccine (Vanderpool, 2011). A study conducted in rural Appalachia, Kentucky revealed associations between HPV risk perception and Gardasil uptake.
This region of the U.S. contains some of the poorest counties in the nation and is recognized for higher rates of cervical cancer prevalence and mortality and lower rates of pap testing. Two of the seven variables in the study demonstrated significant associations with vaccine uptake. Interestingly, perceived likelihood of HPV infection was not a predictor of vaccine uptake, however, belief that the injection would be painful was a predictor. Also associated with vaccine uptake was the belief that “in general vaccines are a good thing” (Vanderpool, 2011). A mass media campaign can balance the perception of pain against the benefits of the vaccine.
Gain and loss message framing is used to address risk-perception in campaign strategies. Ultimately, the intention to perform the requested behavior with the result of actually performing the requested behavior is the goal of a public health campaign. Messages can be framed in either a positive or negative way, presenting the same information as either a gain or a loss, as lives saved versus lives lost, or as a positive benefit to performing the behavior as opposed to a negative outcome in the absence of performing the behavior.
Research has demonstrated that detection behaviors, in public health, such as cancer screenings are more strongly affected by loss-framed appeals. Prevention behaviors, which are more commonly daily sorts of behaviors that require lifestyle changes such as wearing sunscreen or exercise, have a higher likelihood of being affected by gain-framed messages (Park, 2011). Vaccinations are unique in that loss-framed messages can be effective in promoting one-time prevention behaviors (the three-shot series) and vaccinations differ from other types of prevention behaviors such as condom use, which require repeated, ongoing use.
Perceived susceptibility must also be addressed when framing a message to fit the perceptions of the target population. A.Y. Lee and Aaker (2004), found that a gain-framed message was more effective for low-risk groups whereas a loss-framed message resulted in greater brand acceptability for groups that considered themselves high-risk. With regards to the HPV vaccine, message framing can be applied in order to achieve the maximum affect. A gain-framed message would focus on the benefits of the vaccine, namely prevention of cervical cancer and genital warts.
The contrasting loss-framed message would emphasize the risks of declining the vaccination such as developing cervical cancer. Park’s study (2011) demonstrated that loss-framed messages were more influential in affecting HPV vaccination attitudes as opposed to gain-framed messages. Those who perceived themselves in a low-risk condition were more strongly influenced by gain-framed messages (Park, 2011). To enhance overall campaign effectiveness, message framing must be adequately considered in order to influence attitudes and behaviors.
Although adequate data does not yet exist to determine the appropriate message framing for this mass media campaign’s specific segments of the target population, we opted to utilize a blend of loss and gain-framed messages. For each segment, factual and statistical-based information is communicated in a clear, concise manner. The beneficial and positive aspects of the vaccine are emphasized for the young mother segment and the young working woman segment. Additionally, the element of pain is addressed for these two segments by appealing to the positive outcomes of the vaccination. The message for the college student is somewhat more loss-framed, referring to the overall high prevalence of the disease among women in the age group.
The message for the young college student is as follows: “For Your Future. Over 25% of U.S. women are estimated to be infected with HPV. Women ages 20-24 experience the highest rates of infection at 45%. Reduce your risk of cervical cancer… Ask your health care provider about the HPV vaccination before age 26.”
The message for the young mother is: “For Your Future. HPV types 16 and 18 are responsible for over 70% of cervical cancers. The HPV vaccine demonstrates close to 100% efficacy in preventing precancerous cervical cell growths. Protect your future. Reduce your risk of cervical cancer. Ask your healthcare provider about the HPV vaccination before age 26. A few moments of discomfort are worth the peace of mind.”
The message for the young working woman is: “For Your Future. HPV can cause cervical cancer and genital warts in both men and women. The HPV vaccine protects against two types
of HPV that cause 70% of cervical cancers and two more types that cause 90% of genital warts. Reduce your risk of cervical cancer and genital warts. Ask your health care provider about the HPV vaccination before age 26. A few moments of discomfort are worth the peace of mind.”
Media Channel for Each Segment
Media Channel for the Young College Woman: Print media for this segment will include ads in population-relevant magazines, brochures for key placement on campus and materials for campus-based public health educators, bookmarks, posters, and magnets with dates of immunization schedule. Additionally, college campus health leaders will be provided with intervention/ promotion guidebooks and materials. Finally, college campuses will begin a free cervical cancer screening program.
Media Channel for the Young Mother: Print media for this segment includes posters for WIC offices and county social service centers, posters for bus stops, brochures for pediatric and family health clinics, and magnets with immunization schedule. Press kits will be prepared with segment-appropriate news releases as well as a radio commercial. A free cervical cancer screening program will be implemented through county health clinics.
Media Channel for the Young Working Woman: Print media for this segment includes posters for bus stops, billboards, magazine ads, and magnets with immunization schedule. Speaker kits will be provided for community health advocates. Vouchers for a free first immunization will be offered through major insurance providers and through county clinics for the uninsured. A sliding scale will be offered for uninsured consumers. Free cervical cancer screening programs will be offered through county health clinics.
Plan for Dissemination
Ultimately, campaign efforts will take place over the period of one year. During the first three months of the campaign, efforts will be focused on educating political leaders and community health professionals as well as public health advocates and volunteers. “Advocacy kits” will be sent to political representatives. All print materials will be distributed to college campuses, public health centers, social service agencies, and medical centers. During the second phase of the campaign, from three to nine months, the marketplace will be saturated with print and media messages surrounding HPV and the benefits of the vaccine. Billboards will be displayed along with bus stop posters and WIC office posters.
Television broadcasts and press releases will feature keynote speakers from the field of STI and cervical cancer prevention. Female celebrity placement and support will be utilized during several press releases. Radio commercials will promote free cervical cancer screening programs and magazine ads will be printed. The last phase of the campaign consists of advocacy and promotion through community-based efforts, drawing attention to free screening programs and voucher programs. Promotion will continue through radio commercials with three distinct commercials targeting each of the three segments.
Evaluation
Data following baseline will be gathered through surveys. Evaluation efforts will seek to determine three post-intervention outcomes, the number of women screened for cervical cancer, the number of women who initiated vaccination, and the number of women who completed the vaccine regimen. Women in the target population will be surveyed once per year for three years to determine program impact. Secondary data will seek to explore associations between health beliefs and screening and vaccine uptake behaviors.
Based on the Health Belief Model, the survey will include several questions to gauge perceived susceptibility, perceived severity, benefits, barriers, and associated risks of the vaccination. The Health Belief Model can be used as a guiding framework in HPV risk-related research (Vanderpool, 2011). Health care providers will also be surveyed to determine perceptions of most useful to least useful interventions and campaign strategies.
References
- Dunne, E. F., Sternberg, M., Markowitz, L. E., McQuillan, G., Swan, D., Patel, S., & Unger, E.R. (2011). Human Papillomavirus (HPV) 6, 11, 16, and 18 Prevalence Among Females in the United States—National Health and Nutrition Examination Survey, 2003–2006: Opportunity to Measure HPV Vaccine Impact? Journal of Infectious Diseases, 204: 562-565.
- Health Development Agency (2004). The Effectiveness of Public Health Campaigns. Retrieved from http://www.nice.org.uk/niceMedia/documents/CHB7-campaigns-14-7.pdf
- Merck & Co., Inc. (April 2011). Gardasil vaccine: Boys Can be Affected by HPV Disease Too. Whitehouse, N.J.: Merck, Sharp & Dohme Corp.
- Park, S. Y. (2012). The Effects of Message Framing and Risk Perceptions for HPV Vaccine Campaigns: The Role of Regulatory Fit. Health Marketing Quarterly, 29: 283-302.
- Schiller, J. S. (2009). Vaccination Coverage Estimates from the National Health Interview Survey: United States 2008. Health E-stat.
- Vanderpool, R. C., Casey, B. R., & Crosby, R. A. (2011). HPV-Related Risk Perceptions and HPV Vaccine Uptake Among a Sample of Young Rural Women. Journal of Community Health, 36:903-909.
