Abstract
Human papillomavirus (HPV) vaccination rates are significantly lower than recommended targets. Public awareness campaigns can raise awareness of the severity and prevalence of HPV infection and the cancer prevention benefits of the vaccine. We conducted an environmental scan of HPV vaccine public awareness campaigns during the summer of 2014. We used online search strategies and expert input to identify candidate campaigns. Multiple study investigators reviewed all data abstraction and analysis. After applying our inclusion criteria, we identified 14 campaigns with parents or teenagers as the target audience. We characterized campaign messages according to constructs of the Health Belief Model. Most messages focused on the cancer prevention benefits of HPV vaccine; few addressed psychological or practical barriers to getting or completing the vaccine. Four of 14 campaigns had pre- or postcampaign data readily available, only 2 used vaccine outcomes in their evaluations. We concluded there was a high prevalence of HPV vaccine public awareness campaigns but little available evidence on their impact on intermediate or vaccine outcomes.
Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (Centers for Disease Control and Prevention [CDC], 2014b). Approximately 79 million U.S. residents have HPV, and about 14 million new HPV infections occur every year (Markowitz et al., 2014). Most men and women will get at least one type of HPV at some point in their lives (CDC, 2014a). HPV causes genital warts, cervical cancer, and other less common cancers, such as cancers of the vulva, vagina, penis, anus, and throat (CDC, 2014a).
The Food and Drug Administration has approved two vaccines to protect against HPV types 16 and 18, which account for approximately 70% of cervical cancer cases (CDC, 2012). One of the vaccines also protects against HPV types 6 and 11, which account for approximately 90% of cases of anal and genital warts (CDC, 2012). Both vaccines require three shots over 6 months for full protection. The CDC’s Advisory Committee on Immunization Practices in 2006 recommended routine HPV vaccination for adolescent girls, and in 2011 extended the recommendation to adolescent boys. The Advisory Committee on Immunization Practices recommends the immunization at ages 11 and 12 because this age-group has a stronger antibody response to the vaccine than older age-groups and because the vaccine is most effective before HPV exposure occurs (CDC, 2011b, 2013c; Markowitz et al., 2014).
In 2012, only about 33.4% of U.S. females and 6.8% of U.S. males ages 13 through 17 had received all three doses (CDC, 2013a), far short of the 80% goal set by the Healthy People 2020 objectives (U.S. Department of Health & Human Services, 2014). Barriers to parental consent to HPV vaccine may include access, cost, fears of the vaccine’s effect on teen sexual behavior, low perceived risk of HPV infection, or lack of information about the vaccine, including its recommendation for both boys and girls (Holman et al., 2014).
Optimal approaches to educational interventions for HPV are not well understood (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). However, public awareness campaigns have successfully influenced individuals to obtain vaccinations against other diseases, such as influenza (Shropshire, Brent-Hotchkiss, & Andrews, 2013). For HPV, vaccine acceptability may be higher when people believe the vaccine is effective and HPV infection is likely (Brewer & Fazekas, 2007). Public awareness campaigns can rapidly communicate messages about vaccine effectiveness and the high prevalence of HPV to large numbers of people (Jacobsen & Jacobsen, 2011). Such campaigns are most effective when they follow key steps in the social marketing process, such as conducting formative research, message testing, and campaign evaluation (Grier & Bryant, 2005).
To the best of our knowledge, no previous research has explored trends in HPV vaccine public awareness campaigns. We conducted this environmental scan to identify HPV vaccine public awareness campaigns and characterize each campaign’s messages using the Health Belief Model. The Health Belief Model provides a framework for understanding and studying the factors that influence health behavior choices (Shafer, Cates, Diehl, & Hartmann, 2011). It is considered particularly relevant for explaining onetime behaviors like vaccination (Gargano et al., 2014), and it has been used previously to characterize HPV vaccine messages (Shafer et al., 2011; Figure 1).
Health Belief Model Adapted for HPV
Method
An environmental scan uses a variety of approaches to collect information about public health programs (Rowel, Moore, Nowrojee, Memiah, & Bronner, 2005). We conducted an environmental scan to learn from HPV vaccine campaigns present in and missing from the research literature. Our environmental scan used a structured literature search, a targeted search, and expert input.
For our structured literature search, in June and July 2014, we used Google and PubMed to search for the following terms: “HPV” or “cervical cancer;” and “vaccine” or “vaccination” or “immunization;” and “campaign” or “program” or “awareness.” For each search result that referenced an HPV vaccine campaign, we conducted a targeted search to collect campaign materials, such as print resources, social media pages, mobile apps, and media mentions.
We also conducted a targeted search for campaigns that received funding during 2013 from CDC to increase HPV vaccination coverage among adolescents (CDC, 2013b). Some of these grantees used campaign messages and materials that CDC (2012) developed using formative research. Other grantees used the CDC funding to create their own campaign messages and materials. Finally, we enlisted the opinion of HPV vaccine education experts and invited their assessment of the completeness of our candidate campaign list.
We defined an HPV vaccine public awareness campaign as an organized effort to disseminate messages promoting HPV vaccine to adolescents and/or their parents in a particular geographic area. We included campaigns that were in English, targeted the United States or countries generalizable to the United States, and were accessible online. Campaigns also had to target youth ages 9 to 14 years or their parents, include HPV vaccine–specific material, have identifiable primary messages, and use more than one communication channel. Finally, campaigns had to use active outreach strategies rather than passively serving as information clearinghouses. We excluded campaigns with antivaccination messages.
For each included campaign, we collected data on location, sponsor, funding, date launched, target audience(s), communication channels used, overall look and feel, primary messages, research used in campaign design, and evaluation of the campaign’s impact. Two reviewers independently abstracted data; discrepancies were resolved by reviewing findings together and reaching consensus. For campaigns with multiple resources and/or multiple messages, we focused our analysis on a subset of materials that best described the campaign messages. One reviewer identified one to four primary messages from each campaign; the research team then discussed and refined through consensus.
After identifying primary campaign messages, we categorized each message under the Health Belief Model. Two members of the research team independently reviewed each message to determine whether it addressed one or more of the following Health Belief Model constructs: perceived severity, perceived susceptibility, perceived benefits, perceived barriers, self-efficacy, and cues to action. The research team discussed the categorization of each message and resolved differences through consensus.
For each included campaign, we conducted targeted searches of sponsor websites and the scientific literature to identify information on pretesting or formative research conducted before campaign launch and any data available on postlaunch evaluation. We abstracted data on what outcomes were included in the evaluation and briefly summarized the findings.
Results
Our initial search yielded 74 candidate campaigns. We excluded 60 campaigns that failed to meet our inclusion criteria. For example, we excluded campaigns targeting college students because we sought to focus on campaigns targeting adolescents and their parents. After applying our inclusion criteria, 14 campaigns remained in our environmental scan (Table 1).
Summary of HPV Vaccine Public Awareness Campaigns Found in Search June-July 2014
NOTE: HPV = human papillomavirus; CDC = Centers for Disease Control and Prevention; NIH = National Institutes of Health; NC TraCS Institute = North Carolina Translational and Clinical Sciences Institute; Pb = parents of adolescent boys; Pg = parents of adolescent girls; Mg = mothers of adolescent girls; B = adolescent boys; G = adolescent girls; YW = young women.
Characteristics of the included campaigns are listed in Table 1. The six most recent campaigns are among 11 recipients of the 2013 CDC grants for increasing HPV vaccination coverage among adolescents. The remaining CDC grantees had not yet launched their campaigns or made campaign materials available online during our search period.
The campaigns used an average of 6.7 communication channels. The most commonly used channel was a campaign website, not surprisingly since our inclusion criteria required campaign materials to be available online. Other frequently used communication channels include the following: posters (10 campaigns), resources for providers (9 campaigns), and social media (7 campaigns). Less frequently, campaigns included channels such as transit ads, infographics, comics, and mobile apps.
Seven campaigns (50%) featured a primary message of “HPV vaccine is cancer prevention” or similar wording. Three campaigns featured a primary message of “If there were a vaccine against cancer, wouldn’t you get it for your kids?” or similar wording. Both of these messages are used in publicly available CDC resources. Other messages present in multiple campaigns include variations on the theme, “Protect your child” (three campaigns) and “Teens need vaccines, too” (two campaigns). The HPV Vaccine Project in North Carolina is one example of a campaign using the “Protect your child” message, as shown in Figure 2.
Poster From The HPV Vaccine Project, North Carolina
Each campaign message fit into at least one construct of the Health Belief Model. For example, the frequently used message “HPV vaccine is cancer prevention” refers to perceived benefits of vaccination. The message “One in two people will get HPV, which can lead to genital warts and cancer” refers to both perceived susceptibility and severity of HPV.
Table 2 illustrates the most commonly referenced constructs of the Health Belief Model. The largest number of messages (24) highlighted perceived benefits of HPV vaccination, with 15 focusing specifically on cancer prevention benefits. Six messages targeted perceived barriers to vaccination, with five addressing practical barriers (e.g., cost or convenience) and one addressing psychological barriers (e.g., concerns that the vaccine would encourage sexual activity). Only two messages addressed perceived susceptibility, and one addressed perceived severity.
Health Belief Model Constructs Referenced by Human Papillomavirus Vaccine Public Awareness Campaign Messages
NOTE: Some messages referenced more than one construct.
Our targeted searches uncovered four campaigns with postcampaign evaluations available online: Protect Him (North Carolina; Cates, Diehl, Crandell, & Coyne-Beasley, 2014), The HPV Vaccine Project (North Carolina; Cates, Shafer, Diehl, & Deal, 2011), causethemovement (Kentucky; Casey, 2012), and the HPV school vaccination program (Australia; Kellard & Myers, 2013). The two North Carolina campaigns also have published articles describing the formative research and pretesting conducted prior to launching their campaigns (Cates, Ortiz, Shafer, Romocki, & Coyne-Beasley, 2012; Shafer et al., 2011). Both campaigns conducted focus groups and intercept interviews with their target audiences and used the results to inform the development of campaign messages and images.
The four campaigns with available evaluations used several metrics to assess their impact (Table 3). causethemovement (Casey, 2012) focused on direct measures of campaign impact, such as online and social media traffic. In comparison, Protect Him (Cates et al., 2014) focused on the indirect measure of vaccination rates in intervention versus control communities. The HPV vaccine project (Cates et al., 2011) and Australia’s HPV school vaccination program (Kellard & Myers, 2013) both examined multiple measures of campaign impact.
Metrics Used in Evaluations of HPV Vaccine Public Awareness Campaigns
Less Immediate, Indirect OutcomesNOTE: HPV = human papillomavirus.
According to a conference abstract describing causethemovement’s evaluation, the campaign created a high awareness of HPV vaccination and cervical cancer prevention by achieving more than 10,000 “likes” in 1 month on Facebook (Casey, 2012). The evaluation concluded that further research could employ surveys or analyses of medical data to determine whether the campaign led to behavior change (Casey, 2012).
Protect Him’s evaluation found during the campaign period, boys in the intervention counties were significantly more likely to receive HPV vaccine during a clinic visit for other preteen immunizations compared with boys in the control counties (Cates et al., 2014). However, the evaluation noted that three out of four clinic visits for other immunizations for adolescent boys represented missed opportunities to provide HPV vaccine (Cates et al., 2014).
The HPV Vaccine Project’s evaluation found the campaign had a mixed impact on vaccination rates and a larger impact on direct outcomes such as awareness. After 6 months of the campaign, HPV vaccination rates for girls age 9 to 13 were higher in two intervention counties (7.1%, p < .01; 6.8%, p < .01) and lower in two others (3.2%, p < .01; 1.9%, p < .01), compared with a vaccination rate of 5.0% in 96 nonintervention counties (Cates et al., 2011). Surveyed mothers reported a high awareness of campaign messages and materials, and those who were aware of the campaign were more likely to report taking action, such as talking to their doctor or their daughter. The evaluation recommended using multiple channels to communicate campaign messages, and distributing materials during late summer to coincide with back-to-school reminders for other immunizations (Cates et al., 2011).
An evaluation of Australia’s HPV school vaccination program found overall awareness of the campaign was fairly low, with 14% of surveyed parents recalling seeing any element of the campaign (Kellard & Myers, 2013). However, parents and guardians who had seen campaign materials reported a better understanding of HPV and the program compared with those who had not seen the materials. Evaluators suggested that improved distribution of campaign materials could generate greater awareness of HPV and the vaccination program. Evaluators also recommended strengthening campaign materials by adding more information about the benefits of HPV vaccination, particularly for males (Kellard & Myers, 2013).
Discussion
We conducted an environmental scan to identify HPV vaccine public awareness campaigns using constructs of the Health Belief Model, and to describe data on campaign evaluations. We identified 14 campaigns targeting adolescents and/or their parents in Australia, Canada, the United Kingdom, and the United States. Most campaign messages focused on communicating the vaccine’s cancer prevention benefits. Four of the campaigns had evaluation data readily available; two of the four examined vaccination outcomes and three looked at intermediate outcomes such as campaign reach and awareness.
Multicomponent public health campaigns can have a larger impact on health behavior than campaigns employing a single channel (Cates et al., 2011; Robinson et al., 2014). The campaigns in our scan used an average of 6.7 communication channels. Though we required two or more channels for inclusion in our scan, every included campaign used at least 3 communication channels and 3 campaigns used 10.
CDC’s message of “HPV vaccine is cancer prevention” appeared in half of the campaigns we examined, and many of these campaigns are using CDC’s publicly available print materials. CDC conducted formative research when developing its materials, but it is unclear whether the materials would be well received in all locations and among all populations. A key step in social marketing is conducting formative research to gain a deep understanding of a target audience’s attitudes, values, and preferences (Grier & Bryant, 2005). If health agencies disseminate CDC’s materials without conducting their own pretesting, their campaign might not resonate with the local target audience. For example, CDC’s print materials primarily feature images of adolescents by themselves. However, two campaigns with published formative research found that their target audience liked images of parents with adolescent children (Cates et al., 2012; Shafer et al., 2011). Although this preference might be specific to these campaigns’ target audiences, it highlights the importance of using formative research to tailor campaign messages and materials to specific populations.
We relied on the Health Belief Model to characterize campaign messages because it is widely used to explain health behaviors, particularly vaccination uptake (Brewer & Fazekas, 2007; Cassidy, Braxter, Charron-Prochownik, & Schlenk, 2014; Reiter, Brewer, Gottlieb, McRee, & Smith, 2009), and Health Belief Model constructs are predictors of parents’ HPV vaccine decisions (Brewer & Fazekas, 2007; Reiter et al., 2009). Other models, such as the Theory of Planned Behavior and the Integrated Behavioral Model, have been used to explain HPV vaccination decisions by accounting for individual attitudes that are unlikely to be addressed in a public awareness campaign (Dillard, 2011; Gerend & Shepherd, 2012). Future research might explore how public health campaigns employ interpersonal- and community-level strategies to shift attitudes and social norms around HPV vaccination using socioecological models as a guiding strategy.
HPV vaccine acceptability is highest when people believe the vaccine is effective, HPV infection is likely, and barriers to vaccination are addressed (Brewer & Fazekas, 2007). The majority of campaign messages reviewed in this environmental scan emphasize the perceived benefits of HPV vaccination, and specifically cancer prevention benefits. However, few campaign messages address barriers to vaccination and even fewer highlight susceptibility to HPV. This suggests opportunities for future campaigns. Interventions that address parents’ fears about vaccination and provide information about disease susceptibility have been shown to improve parents’ attitudes toward childhood immunizations (Williams et al., 2013). Thus, future HPV vaccine campaigns should consider messages that address vaccination barriers and emphasize the high likelihood of HPV exposure.
Parents are more likely to vaccinate their children against HPV if they receive a recommendation from a health care provider (Brewer & Fazekas, 2007; Dempsey, Abraham, Dalton, & Ruffin, 2009; Griffioen et al., 2012; Reiter et al., 2009). It is promising that 9 out of 14 campaigns in this environmental scan include provider resources as a communication channel. Such resources aim to facilitate conversations between parents and providers about HPV vaccination. However, only one campaign includes an explicit provider recommendation as a primary campaign message (“I recommend it, not just because I’m a doctor, but because I’m a parent.”). Nine campaigns include a cue to action among their messages, but only two of these were cues to “talk to your provider.” Such explicit cues could encourage more parent–provider conversations about the vaccine. Although campaigns featuring provider-related cues did not have evaluations available, the strong evidence for provider influence on parents’ vaccination decisions suggests that strong physician recommendations may be worth exploring.
Limitations of this environmental scan include our focus on campaign materials that were available online. As a result, it is possible that some campaigns had components or evaluations we were unable to access. We may also have excluded some initiatives that did not otherwise fit our definition of a campaign or our inclusion criteria. These initiatives may provide information that can inform future campaigns. However, anticipating a large volume of search results we chose to define our inclusion criteria a priori, consistent with best practices for structured literature reviews.
National attention to HPV vaccine is rapidly evolving, with initiatives launched by the President’s Cancer Panel and CDC. As such, this scan can only capture a cross section of campaigns available at the time of our search. As other campaigns launch, we hope our report will serve as a baseline for future reviews.
Presumably all campaigns strive to improve HPV vaccine uptake, and aim to do so through raising awareness. However, only four campaigns had evaluation data readily available and only two campaigns evaluated impact on vaccine rates. For organizations looking to conduct evidence-based outreach, this lack of evaluation data could be problematic. A public awareness campaign may be an insufficient “dose” to affect vaccination rates, but one launched in the context of a multilevel approach including providers, peer-to-peer outreach, and policy-level interventions may be the most likely to affect vaccination uptake. Multilevel approaches likely will involve significant resources, so implementing evidence-based campaigns is crucial.
The four evaluated campaigns offer limited lessons for organizers of current and future HPV vaccine campaigns. Additional evaluative research is needed to draw meaningful conclusions about the attributes of effective HPV vaccine public awareness campaigns. Such research may be forthcoming, as several CDC-funded campaigns launched during our search period and may undertake evaluations. Organizers of current and future HPV vaccine campaigns should conduct rigorous evaluations to contribute to this limited knowledge base.
We recommend campaign organizers use existing evidence where possible and, if not available, conduct and make publicly available local formative research. Formative research helps social marketers better understand a target audience and the messages most likely to resonate with that audience. In addition, postlaunch campaign evaluations offer insight into the effectiveness of different messaging in different contexts. As more HPV vaccine public awareness campaigns launch, formative and evaluative research will be crucial to identify strategies most likely to spur behavior change among specific populations. Such research will offer valuable lessons to organizers of future campaigns and facilitate further study into the characteristics of successful campaigns.