Wednesday, June 8, 2011

Improving HPV Vaccine Intervention through Social Science Theory- Alexandra Hulme

Public Health Problem

In June of 2006, the FDA approved the vaccination Gardasil for females between the ages of 9-26 to protect against types 6,11,16 and 18 of the Human Papillomavirus (HPV) that indicate an association to genital warts and cervical, vulvar and vaginal cancers, respectively (1). This vaccine was a game changer in the medical field as it was the first of its kind to show 100% efficacy in preventing cancers, in this case those caused by those strains of HPV (2). While it usually takes 10-15 years for cervical cancer to develop from first HPV infection, the best time to vaccinate is before a female’s first sexual experience, due to the high prevalence of HPV: 39.6% in women ages 14-19 and 49.3% in women ages 20-24 (3). The lag time between infection and development of cervical cancer and the high prevalence rates, and the nature by which HPV is contracted - typically sexual interaction - makes it a very unique vaccine to promote and support.

Merck, the developer of Gardasil, employed several campaigns to promote Gardasil, including an unbranded educational, pre-release campaign, the “One-Less” campaign and the “Tell Someone” campaign (A. Mueller, personal correspondence, 7 March 2011). All of these campaigns had to promote the vaccine to a wide aged cohort, because the vaccine was suggested for women ages 9-26. This makes its universal acceptance difficult because the way in which these target audiences need to be addressed, especially in relation to such a polemic topic. By 2008, 37% of the 9-26 female population had received the vaccine (3), but there was still reluctance in widespread acceptance of the vaccine. This paper will provide three critiques of the current HPV prevention campaign and then provide three suggestions for improved interventions to increase both awareness and acceptance of the vaccine.

Critique # 1

Failure of the Health Belief Model

The GARDASIL campaign was heavily grounded on two un-branded campaigns that served to educate the public about HPV, its connection to cervical cancer and new technologies that are being developed to prevent the disease. These campaigns were successful in increasing awareness and knowledge to both mothers and young adults, showing an increase from 5% awareness to over 50% awareness of the link between HPV and cervical cancer (4). The objectives here fall in line with the Health Belief Model approach to public health campaigns, that focus on increasing knowledge to affect an individual’s perceived susceptibility to contracting a disease and the perceived severity of the outcome (5). As an individual starts to perceive an increased risk of the negative outcome, they will then rationally do what is needed to protect themselves (6). In the case of GARDASIL vaccination, the idea was to increase perceived susceptibility to HPV and cervical cancer and then the women, with their newfound education, would take the appropriate steps towards vaccination. This approach however is flawed; an individual’s health decision is not rational, and the balance between costs and benefits do not always dictate intention to act and behavior. The health belief model has little strength in accounting for the variety of behaviors that are related to attitudes and beliefs, because there are a variety of forces that can influence and individual’s behavior (7). While education is an important component in any public health campaign, especially when there was little previous knowledge about the connection between HPV and cervical cancer and the susceptibility to such diseases, a successful campaign cannot depend on education alone.

Merck highlights young adult females as one of the primary target groups for the campaign and vaccination (A. Mueller, personal correspondence, 7 March 2011). They were the center for many focus groups and education campaigns to improve their education on the subject of HPV and cervical cancer in an attempt to get them to seek out the vaccine. A large flaw in this approach is the assumption that just because people have knowledge they will act in a responsible manner to mitigate the threat (perceived severity and susceptibility to HPV and cervical cancer). This increased knowledge was shown to be successful, but did little to influence their perceived susceptibility, even though they are at a high risk due to their sexual behavior (8). As a behavioral economist, Dan Ariely and others have demonstrated, humans are not the rational, predictable creatures that the Health Belief Model would like to believe they are. People are influenced by stereotypes, labels and expectations, which changes their behavior and causes them to act differently based on cultural expectations (9). In most situations when something is considered dangerous, such as risky sexual behavior, there is a tendency to want to continue with that behavior, because the consequences of one’s actions are not usually considered in the moment, nor is one’s intention to act an automatic stimulus for expected behavior. Education and awareness of a disease does not automatically result in change behavior and increased used of the HPV vaccination.

Specifically in this campaign, more emphasis was placed on GARDASIL as a preventative vaccine for cervical cancer, instead of its clinical prescription as a vaccine for HPV. In an attempt to be less controversial for the mother’s of young girls (a target audience), the anti-cancer campaign was more effective than an HPV driven campaign and increased the mother’s perceived threat and susceptibility for their daughters (10). This push to educate mothers, focused on mother’s telling or taking their daughters to get vaccinated and not on creating an incentive or reason YAFs to get vaccinated. Eliminating the connection between HPV and cervical cancer discouraged YAFs from getting the vaccine, because even though they had information from the campaign, it was not appropriate for their needs or demographics. (4,10, 8). The campaign failed in its education campaign because it limited what information was transferred to target audiences, not that it lacked the knowledge to educate their audiences. This element played into the ineffectiveness of the education campaign because while there was increased knowledge, individuals behave irrationally and could not connect their actions and perceived risks indicated to them to change their behavior.

Critique # 2

Limitations of Social Norms and Sex

The connection between HPV and cervical cancer and the need to spread the message to such a large target audience (girls 9-26 years old, FDA recommendation), posed a daunting question for promoters. Researcher Suellen Hopfer comments that this vaccine posed a “new challenge in health message design because promotion of the vaccine raises questions inextricably linked the sexual health and cancer – both topics that are culturally sensitive and taboo” (11). In following the social norms theory we know that people’s behavior is largely driven by social norms, but it is hard to know what the norms are. The current social norms that dictate our society downplay the discussion of sex and sexually transmitted diseases, though HIV/AIDS has probably improved the situation. Because of this sexual taboo, the discussion of HPV as a sexually transmitted infection was heavily downplayed in the campaign (10). The campaign focused on parents and getting mothers to take their younger daughters to get vaccinated, but for many, thinking about the future sexual activity of their daughters is not something which they regularly consider (A. Mueller, personal correspondence, 7 March 2011). Thus, the campaign focused on promoting GARDASIL as a cervical cancer vaccine, so as not to be so divisive with parents and thoughts of their young daughters being sexually active, if not now then in the future (12).

In devising a campaign that emphasized the prevention of cervical cancer, the marketers were able to heavily bypass that conversation and successfully appeal to the mothers of the girls on the younger end of the target audience. This approach maximized the threat of cervical cancer and HPV to adolescents, while minimizing those who were most at risk (10). Merck recognized the limitations that our cultural sensitivity would do to the appeal of an HPV vaccine if it were marketed as such (4). While this aspect allowed it to draw in a large population of younger girls, who were brought to get vaccinated by their mothers, the campaign’s focus on cervical cancer ignored and isolated young adult females (YAFs), limiting the effectiveness of the campaign on that age demographic (13).

Because the campaign focused on cervical cancer, the social norm regarding HPV vaccination in YAFs was very seldom looked at. Following the social norms theory, social norms affect human behavior, but there was little arena for the discussion of what the social norm is, within the context of HPV and who was getting or not getting vaccinated. Hopfer discovered that is hard to reach college age women because it is hard to know the types of messages they receive in regards to such stigmatizing topics like HPV (11). The failure of the campaign directed at YAFs was so unsuccessful that Merck ended up pulling the funding for that entire component of the campaign (A. Mueller, personal correspondence, 7 March 2011). It was clear in focus groups that YAFs knew about their risks and did not react, they did not relate to cervical cancer message tilt of the marketing campaign, which was guided by the social norms of our times.

Critique # 3

Lack of Self-Efficacy and the failure of the Theory of Planned Behavior in HPV Vaccine Interventions

The existing campaign encouraging HPV vaccination provides lots of information to potential vaccine candidates, but does little to account for their actual intention to change their behavior in regards to safer sex and getting the HPV vaccination to prevent an HPV infection or cervical cancer. The Theory of Planned Behavior, developed by Ajzen and Fishbein, is the weighing two things against each other: outcome expectancies of the behavior and perceived norms, which lead to and dictate intention to act, which will lead to behavior (6). Included is also the component of self-efficacy of perceived behavioral control: a person’s belief that they are capable of doing a behavior, which is another influential element in the process to actually performing a certain behavior. An appeal to one’s self-efficacy in actually changing their behavior is thus necessary for any successful campaign.

However, the current HPV intervention is unsuccessful at appealing to this need and desire. By simply providing information to the targeted demographic about the dangers of HPV or cervical cancer, little connection is being made to the individual and their ability to change their behavior. Ajzen’s theory proposes that perceived behavioral control can influence behavior directly and that those with higher perceived control are more likely to form intentions to perform a particular action than those who perceive they have little or no control (14). Media campaigns, like GARDASIL, predominantly addressed the mother of adolescents, to get the vaccine for their daughter, but ignored the needs of the adolescents or young adult females themselves in seeking their own change in behavior (13). In following the theory of Planned Behavior, this does not allow the individual the opportunity to weigh the outcome expectancies or perceived norms themselves which will lead to intention and behavior change.

Researcher M.C. Yzer and colleagues analyzed several safer sex campaigns and their effectiveness on self-efficacy, along with other variables (15). They found that planned behavior in relation to safer sex (which also relates to HPV transmission) actually changed people’s behavior. However, their results show that these changes dropped, when the mass media campaigns dropped, indicating the need for campaigns to maintain high levels of determinants of safer sex, because they are effective for stabilizing and enhancing determinants of safer sex behavior (15). This demonstrates the ability of and need for campaigns that do not just inform, but that show individual’s their ability to change what they do and how they behave for the better, in a demographically specific environment.

Because the HPV intervention does not emphasize and individual’s power or control, but depends on that of her mother or peer, she is unable to take the necessary steps towards behavior change, driven by her own self-efficacy. As shown in another study on condom use, chronic perceptions of HIV risk are minimally linked to preventative behavior (14). This shows, that even with all the information promoting the dangers of not getting the vaccine and the potential consequences, those who are at risk or believe they are risk, are not likely to change their behavior because of that perception.

It is not just the knowledge that is necessary, but also the tools to enact that knowledge which will lead to greater self-efficacy and behavior change. The GARDASIL campaign fails to address this need of self-efficacy, though that is usually an important factor in mediating the relationship between knowledge and behavior (16). The ‘One Less’ campaign focused on an individual joining a movement and deciding for themselves to be one less person who gets cervical cancer, it did not take the next step in showing their target audience how to actually take that step, and make that change for themselves. It empowered through knowledge, but not through action and behavior. Had the campaign focused on improving confidence in the ability to enact healthy behaviors, then the desired change would follow, because the campaign would focus on efficacy expectations not just information dissemination, as was shown to work in a study on exercise behavior. This study also showed that those with greater levels of self-efficacy engage more often in and tend to stick to a regular schedule of physical activity, indicating the importance of regular reminders and campaigns to maintain behavior change, similar to the results of the safe sex campaign study (15,16).

In failing to appeal to what Ajzen’s theory of planned behavior proposes: perceived behavioral control can influence behavior directly (14), the current HPV intervention is inadequate. In 2008, only 25% of US females 13-17 had received the started the vaccination, though HPV prevalence in the 14-19 year age group is 39.6% (2). The study showed that while 90% of adolescents and young woman understand that the best time to get vaccinated is before their first sexual experience, and that they show high levels of acceptance of the vaccine, actual vaccination rates are low (2). The information from the campaign is reaching its audience, but is not influencing their behavior, and that is the most key factor because, it is only behavior change that will improve the health of targeted demographic.


Redirecting the Campaign – Beyond Education

The Health Belief Model is limited in its effectiveness and as a result GARDSASIL’s campaign is flawed. Education campaigns need to value how the message is developed and administered to the target audience. The campaign should focus on psychology of persuasion and entice people to get the vaccine, not just through education, but by promising them something more exiting in return for an intentional behavioral change (having protected sex and getting vaccinated). The promise of the campaign needs to come from a messenger that the YAF population likes, focusing on similarity and familiarity to develop a meaningful association between the audience and the message. The manner in which the request is structured can and should be tied to a specific, stored trigger and thus direct the individual to the action that is desired (17). Understanding that education will not change or influence an individual’s behavior because she is predictable yet irrational, the campaign should play into these characteristics to increase success and the ownership of their decision, their body and the value of preventing HPV and cervical cancer. Increasing the value of the vaccine for YAFs is very important because, as it stands now, there is a limited connection in the campaign to something to which they can relate: STIs and unprotected sex. When individuals engage in unhealthy behaviors they own and value their actions, so to change their behavior they need to exchange it for something of higher value. In the case of HPV vaccine, they need to appeal to a value that is higher then health. The campaign could appeal to a cleaner, less risky sex life or focus on the portrayal of a more glamorous life after getting the vaccine and having protected sex, instead of just increasing the education component and pushing the prevention of cervical cancer.


Challenging Social Norms

Without information guiding the social norms of the young adult female cohort, intervention strategies will continue to be ineffective. Research has shown that social influences were key correlates to vaccine decisions (18, 11 ,19), but research regarding what the social norm is and who can influence those is the first step in creating a more successful intervention campaign. A new direction is needed, one that normalizes vaccination within the YAF population and uses peer-led campaigns to encourage future vaccination. This new approach takes advantage of the research findings of (19) who found that the social norm of the HPV vaccination (peers also going to get the vaccine) had the strongest influence on being vaccinated. Additionally, when widespread acceptance of the vaccine is emphasized it will promote further acceptance by others (13).

On college campuses or in workplaces that are predominantly staffed with young adult females, interventions that focus on promoting a unified front of acceptance for the vaccine – a normalized behavior – will continue to reach a wider audience. Showing that more of one’s peers are vaccinated or in the process of getting vaccinated, will push those who are undecided or unsure of what others may think, to do the same, increasing the acceptance for all. Shifting the media campaign that showed mothers can do this and adolescent girls getting vaccinated, to more young adult females (an older age demographic than adolescents) who got vaccinated or are talking with their friends that got vaccinated in a collegiate environment. Another approach would be to increase the distribution of information on the number of women within the targeted age demographic who already got vaccinated. Since it is something that is not easily discussed, showing how commonly accepted vaccination is, will decrease the idea of the HPV vaccine as a taboo subject and will normalize both its discussion and the acceptance of the vaccine. By changing the social norms of our society, behavior change will also be initiated. This part of the program is less education based and more grounded in awareness and discussions of typically culturally taboo subjects of sexually transmitted infections.


Improving Self Efficacy

It has previously been shown that improving one’s self-efficacy will lead to greater health outcomes, something the current HPV intervention does not do. A new way of approaching self-efficacy is to address the barriers that people perceive when they try to get about getting the vaccine or take the first step to change their behavior (14). This idea includes addressing factors such as insurance coverage, history of STI, doctor/family recommendation (2). For example, by limiting the price of the vaccine or making insurance companies cover the vaccine, which is roughly $360 for a full series of three shots (1), women will feel more in control and able to actually change their behavior.

Focusing on the previous similar achievements of an individual can also make improvements to the intervention, because prior performance accomplishments are typically a dependable source of efficacy expectations if they are based on one’s own personal experience (16). The intervention could draw attention to the success of other vaccination campaigns and the frequency with which people seek the flu vaccine or the Hepatitis B vaccine. By demonstrating to the candidates that they have already taken a similar step towards a similar goal in the past, will be motivation and proof, that they are capable of similar behaviors, even if they address another area of health.

Furthermore, reviewing pre-action behaviors can also improve self-efficacy. In a study that looked at condom use and safe sex practices, those who had condoms available and had talked to their partner about using a condom were more likely to use a condom as the “event was under personal control of the client” (14). In relation to HPV vaccination, this could include discussing with peers and family members beforehand, but also looking at choices that those in targeted age demographics have successfully completed beforehand. Since, uptake with YAFs is lower than expected, targeted campaigns that show their self-efficacy and success in moving away from their families, starting a job or going to college, making independent choices about eating, smoking, drinking, sexual, physical behavior, will prove to them they have done something similar before and are capable of doing it again (16).


As a result of the variety of ways in which health campaigns can be designed and disseminated, there are different ways to then also critique and improve. The three critiques above all address different aspects of the current HPV vaccination campaigns from the perspective of the health belief model, social norms theory and theory of planned action, respectively. While they pin point and target to whom the information is given, how the information is given and what the information and campaign addresses, the final goal is to increase acceptance of the HPV vaccine, specifically for the young adult female population. Different individuals with different goals and support devise campaigns such as these and therefore, there is no one right answer. However, using social science theories that are grounded in successful evidence-based approaches can only lead to the future success of public HPV vaccination campaigns.


1)U.S. Food and Drug Administration. Gardasil. (2011).

2) Gamble, Heather, Klosky, James L., Parra, Gilbert R., Randolph, Mary E. (2010). Factors Influencing Familial Decision-Making Regarding Human Papillomavirus vaccination. Journal of Pediatric Medicine, 35(7) 704-715.

3) Centers for Disease Control and Prevention. Vaccines and preventable disease: HPV vaccination. (2011).

4) Herskovitz, B. (2007). Brand of the year.

5) Cameron, K. (2007). A practitioner's guide to persuasion: An overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling, 74, 309-317.

6) Freudenberg N, G. S. (2008). The impact of corporate practices on health: Implications for health policy. Journal of Public Health Policy, 29, 86-104.

7) Salazar, M. (1991). Comparison of four behavioral theories. AAOHN Journal, 39, 128-135.

8) Lopez, R., & McMahan, S. (2007). College women's perception and knowledge of human papillomavirus (HPV) and cervical cancer. Californian Journal of Health Promotion, 5(3), 12.

9) Ariely, Dan. (2008). Predictably Irrational. New York: Harper Collins.

10) Rothman, S. M., & Rothman, D. (2009). Marketing HPV vaccine: Implications for adolescent health and medical professionalism. Journal of American Medical Association, 302(7)

11) Hopfer, S., & Clippard, J. R. (2011). Women's HPV vaccine decision narratives. Qualitative Health Research, (21), 262. doi:10.1177/1049732310383868

12) Dederer, C. (2007, February 18, 2007). Pitching protection, to both mothers and daughters. The New York Times.

13) Marlow, L. A. V., Waller, J., & Wardle, J. (2007). Parental attitudes to pre-pubertal HPV vaccination. Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, UCL.

14) Albarracin, D., Johnson, B. T., Fishbein, M., & Muellerleile, P. A. (2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127(1), 142.

15) Yzer, M.C., Siero, F.C., Buunk, B.P. (2000). Can public campaigns effectively change psychological determinants of sager sex? An evaluation of three Dutch campaign. Health Education Research, 15 (3), 339-352.

16) Rimal, R. N. (2001). Longitudinal influences of knowledge and self efficacy. Journal of Health Psychology, 6(31) vaccination. (2011).

17) Cialdini, R. (2007). Introduction and chapter 1: Weapons of influence. Influence: The psychology of persuasion (pp. xi-xiv, 1-16). New York: Harper Collins.

18) Allen, J. D., Othus, M. K. D., & Shelton, Rachel C., et al. (2010). Parental decision making about the HPV vaccine. Cancer Epidemiology, Biomarkers and Prevention, (19), 2187.

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