Challenging Dogma - Fall 2011

Friday, December 23, 2011

HPV Vaccination Promotion: Current Flaws and Possible Improvements – Allyson Shifley

Approximately 20 million Americans currently have genital human papillomavirus (HPV) infections. HPV is the most common sexually transmitted infection with at least 50% of sexually active people getting HPV at some point in their lives (1). In 2006, the first preventive HPV vaccine was approved for females aged 9-26 by the FDA. In 2009, the vaccine was also approved for males aged 9-26 (2). There are over 40 HPV types that can infect the mouth, throat, and genital areas of both males and females. This vaccine protects against types 6, 11, 16, and 18. Types 16 and 18 primarily cause cervical cancer (1).

HPV is passed on through genital contact (vaginal and anal sex), oral sex, and genital-to-genital contact. Most people do not realize when they are infected, and therefore do not realize they are passing on the infection to their partner. HPV infections can cause genital warts, respiratory papillomatosis (rarely), cervical cancer, and other less common cancers, including cancer of the vulva, vagina, penis, anus, and oropharynx (3). The HPV vaccine can protect both males and females against most types of HPV that can cause disease and cancer and most cervical cancers. If the vaccine is widely adopted, it is estimated it will prevent 70% of cervical cancers in the U.S. (1).

It is estimated that fewer than 11% of girls in the United States have received all 3 doses (4). And in 2010, 32% of the U.S. female adolescent population aged 13-17 had received all 3 doses of the HPV vaccine (5). This is a low adoption rate; kept low by the widespread reluctance to accept the vaccine. This paper will outline the current approach towards HPV vaccination adoption and present its major flaws. Then, following the flaws, possible improvements will be suggested for a new intervention approach to increase the acceptability and adoption rate of the HPV vaccination.

The Current Approach

The current approach toward HPV vaccination is flawed. There are two main faces of pro-HPV vaccination: the Centers for Disease Control and Prevention (CDC) and Merck, the producers of the vaccine Gardasil. The three main flaws in the current approach are the lack of a centralized messenger, the reliance on the Health Belief Model, and an education only promotion approach.

Flaw 1: The Messenger

Public knowledge about HPV is limited. About 40% of women aged 18-75 have heard of HPV and even less than that know its association with cervical cancer (6). Gardasil and the CDC have successfully increased knowledge about HPV. In fact, Gardasil commercials were a common source of information about HPV and have increased people’s knowledge of HPV (7). Still, there has not been enough knowledge disseminated throughout the population, and this is in part because there is not a single leader of the pro-HPV vaccination campaign. There is no point person to rally behind, no leader to give a single voice to the campaign. Currently there are so many opinions, both pro- and anti-HPV vaccination, that parents find it difficult to determine who to trust for safety information (8). And the information available is very contradictory.

Again, the two main faces of pro-HPV vaccination are Gardasil and the CDC. Gardasil is marketed by Merck, a pharmaceutical company. People are wary of Merck, aware that it has motives other than health. Most fault has been found in how Merck has marketed Gardasil. Merck is viewed as marketing Gardasil for self-promotion. Some people blame the wording in these advertisements on misleading the public about how protective these vaccines are and what exactly they prevent against (9). The bottom line is that a pharmaceutical company pushing its own vaccine is not seen as a trustworthy source, with only 2% of parents placing a lot of trust in websites from companies that make vaccines (8).

The CDC is a governmental component of the Department of Health and Human Services. Although its mission is to create information and tools for people to protect their health, a study conducted by Freed et. al. (2011), cites that only 23% of parents reported placing a lot of trust in government vaccine experts and officials (8).

There is a lack of public trust in these messengers. Following communication theory, the source of information is an important consideration to take into effect when trying to transit information to an audience (10). The pro HPV vaccination campaign is using Gardasil and the CDC as their messengers, two sources that the pubic do not have a lot of trust in. Neither messenger inspires trust and neither is a point for which people to rally behind.

Flaw 2: The Reliance on the Health Belief Model

The campaign’s reliance on the Health Belief Model is another fatal flaw. The Health Belief Model depends on affecting an individual’s perceived susceptibility and severity of having the negative health outcome to lead to behavior change. There are four variables to the Health Belief Model. First, an individual needs to be motivated to act in healthy ways if she believes she’s susceptible to a negative health outcome. Second, the stronger an individual’s perception of severity of the negative health outcome, the more motivated she is to avoid the negative outcome. Third, she must believe that the target behavior will provide strong positive benefits, or that the target behavior prevents the negative health outcome. Lastly, if the individual perceives barriers preventing her from adopting the target behavior, then she will be unlikely to adopt the target behavior (11).

In this campaign, the negative health outcome is developing cervical cancer. Although, HPV most commonly causes genital warts, the focus on genital warts as a negative health outcome has largely been dismissed in favor of the focus of cervical cancer. And, the target behavior adoption is receiving all 3 doses of the HPV vaccine. Therefore if the individual perceives an increase in her risk of having cervical cancer, then rationally she will change her behavior and get the HPV vaccine to decrease her likelihood of cervical cancer. However, in a meta-analysis conducted by Carpenter, susceptibility is unrelated to behavior change. And perceived severity of a negative health outcome is the weakest predictor out of the four variables to predict the likelihood of adopting the target behavior. According to this, susceptibility and severity do not affect the person’s motivation to make a positive behavior change. The Health Belief Model relies on rational behavior and logical decision-making process. Humans, however, are not rational supported by the susceptibility and severity not affecting behavior change.

Two variables of Health Behavioral Model do relate to behavior change, benefits and barriers. Barriers are the largest predictor of the four variables. The pro-HPV vaccine campaign, however, does not address these factors to encourage behavior change. And the model does not allow for combating the perceived barriers. The most commonly cited perceived barriers were parental concerns about promoting sexual activity, financing the vaccinations, and low perceived vaccine safety (1, 12, 13). For parents who responded that they would not likely vaccine their daughters before ages 13 or 16, in a survey by Constantine and Jerman, the main reasons concerned pragmatic sexual behavior concerns, HPV vaccine concerns, general vaccine concerns, moral sexual behavior concerns, and denial of any need (14). The current approach does not address these parental concerns. Instead, the campaign focuses on susceptibility and severity – the two factors that do not motivate positive behavior change.

Flaw 3: Education Only Blinds

In addition to the lack of an appropriate messenger and the reliance on an inappropriate model to promote HPV vaccinations, the current promotional approach is flawed. To motivate people to receive this vaccine, the CDC and Gardasil use an educational approach.

The CDC has a Preteen and Teen Vaccine Communication Campaign to improve vaccination rates for several vaccines, one of which is the HPV vaccine. They cater to parents and health care providers of adolescents 9-18, adolescents 9-18, and Public Health professionals promoting immunization. The current objectives include raising awareness and educating parents, educating health care providers, providing communication tools for public health officials, and educating adolescents, all on the importance of vaccinations and on the diseases they prevent (15). The focus is on education, promoting information and statistics through pamphlets, brochures, podcasts, a short video and sending e-cards to others.

Gardasil has promoted the vaccine through the One Less campaign. The campaign is more consumer-oriented with advertisements on television, radio, Internet, and in print (16). But again, it promotes education on HPV and the diseases the vaccine prevents.

The CDC and Gardasil campaigns have been successful raising awareness and knowledge to parents and adolescents (7, 17). These campaigns rely on the Health Belief Model, which is an inappropriate model as addressed in Flaw 2. Still, these approaches use the Health Belief Model in an attempt to increase an individual’s knowledge about the health problem to affect her perceived susceptibility and severity of having the problem. Education alone, however, does not lead to behavior change. One study found that individuals with a higher risk perception were more likely to be vaccinated (13). However, these high-risk perceptions were not formed from educational materials but from emotional appeals and life experiences. For example, parents with a history of genital were more likely to have their child vaccinated (17). A study by Dempsey et al. concluded that providing parents with HPV information improved their knowledge about HPV, however, this uptick in knowledge had little effect on the acceptability of the vaccine (17).

Also, increasing knowledge does not address or make the connection between an individual and her ability to change her behavior. This connection needs to be addressed through ownership of one’s health and through appealing to core values. In addition, it needs to make plans of action to break through perceived barriers.

However, the focus is solely on statistics and education. Insisting that the public should get this vaccine, and only giving the public statistics, actually incites a reactance on the part of the public. Reactance is shown as the backlash against mandates for girls to receive the HPV vaccine for school attendance. A survey found that 57% of US voters opposed Texas’s mandated HPV vaccines (4). And the current political debates show just how powerful this reactance is with Perry reversing his original support for HPV vaccination mandates (18).

The reactance is directly related to how the pro-HPV vaccination advocates are conducting the campaign. The focus on an education only approach blinds the campaign, making in unable to focus on the important factors that could increase HPV vaccine acceptability and awareness. This reliance on an education only approach is a mistake. The CDC focuses on facts and statistics to promote behavior change. This non-causal information does not address people’s concerns with the vaccine. Nor do statistics help people overcome the perceived barriers to receive the vaccine.

The Proposed Intervention

Public health officials, healthcare providers, the pharmaceutical companies, parents, and adolescents needs to work together to create a campaign using social science theories to increase awareness of and acceptability of the HPV vaccine. Currently public trust in immunization is decreasing, with an increasing amount of parents expressing more fear over the vaccine than of the diseases that the vaccine is supposed to prevent (19). Part of this fear is a result of a great number of parents today never experiencing the diseases that vaccines prevent. There are several important differences from the time that vaccines were first introduced and the climate around vaccines today. There has been a dramatic increase in available and recommended vaccines and in mandated immunizations. People increasingly want to understand health issues and want to assume responsibility for their health decisions. The Internet and other social media have rapidly grown and quickly disseminate information and misinformation to the population. People can now look up anything on the Internet and have a flurry of “hits”– but it is not as easy to determine which sites are real and which contain incorrect information. It is also important to realize the extent to which the media has propelled the vaccine controversy. Bad news sells, so any allegation of a harmful effect of a vaccine is more frequently reported (19).

Keeping all of this information about the changing climate around immunizations in mind, I suggest a two-part intervention designed to address the method in which information is disseminated to the public.

The first part concerns the communication skills of the healthcare providers. Healthcare providers are an incredibly important source for health information and immunization information. These providers may have all of this knowledge to give to their patients, but lack the ability to successfully communicate it. To address this, healthcare providers are to attend trainings on social communication, specifically about addressing vaccinations with their patients. Then, they are to establish a checklist for patient visits that includes conversations about sexual activity, and therefore the HPV vaccination. These checklists regulate their visits with patients to ensure these conversations are occurring.

The second part is a campaign to the public to hopefully reach everyone, specifically those who do not regularly visit a healthcare provider. This campaign is to use the principles of social marketing. It will be nationwide, but research will be done to distinguish areas that contain high at-risk populations to aim increased efforts in those areas. At-risk populations and areas have been described in previous research, including African-American and Asian American parents who have reported lower acceptability of an HPV vaccination (14). And, data shows that Hispanic and African-American women are 1.5 times more likely to develop and die from cervical cancer, when compared to white women (6). More research needs to be conducted to identify at-risk populations so that future interventions can be tailored to each racial group or geographic community to address that group’s specific needs (1).

For this intervention to work, the flaws from the current approach to HPV vaccinations need to be addressed. There needs to be an appropriate messenger to give voice to the campaign and for people to rally behind. The approach should not rely on the Health Belief Model. Also it should address parental concerns and broaden the approach beyond just HPV and HPV vaccination education.

Support 1: Getting Healthcare Providers Talking

In one study, 77% of survey respondents reported that their healthcare provider is the most trusted source of health information (7). Healthcare providers are an integral part of making sure their patients are healthy. This involves regular check ups, screenings, tests, and immunizations. It also includes having conversations about health behaviors, immunizations, and any patient concerns. HPV and HPV vaccination discussions should occur during these visits. However, not everyone is having these discussions about HPV vaccines, or vaccines in general, with their doctors. 87% of doctors say they have talked to their patients about vaccines, but only 47% of patients report that their doctor has actually talked to them about them, other than the flu vaccine (20). This is a large disconnect between doctors and patients that needs to be addressed. Social communication strategies can improve this situation.

Social communication is the language used in social situations. It overlaps language abilities and social-cognitive abilities. There are both verbal and nonverbal actions. Healthcare providers need to take into account their patients’ social situations, lives outside of the clinic, and use language that is familiar to the patients. (21)

Healthcare providers need to learn how to present information in perspective– which includes presenting the benefits of the vaccine but also the risks and the gaps in knowledge concerning the vaccine. Taking the time to explain HPV and the benefits, risks, and uncertainties about the HPV vaccination can establish trust and a good relationship with the patient (19).

Support 2: Using Social Marketing Strategies

Although data and rational arguments are important, they are not enough to get people to be vaccinated (22). Social marketing is the use of marketing tools or techniques to induce social and behavioral changes (23). It focuses on using different theories and strategies, drawing from commercial marketing, behavior change theories, social psychology, and human reaction to message, to influence healthy behaviors and improve personal and societal welfares. To successfully induce positive behavior changes, social marketing-led campaigns rely on the 4 P’s of marketing (product, price, place, and promotion) and tailoring the campaign to different population subgroups (22).

The 4 P’s of marketing (product, price, place, and promotion) are instrumental in this process. The ultimate objective is for the target audience to take action, for people to get the HPV vaccination. To do this, the campaign leaders need to design an intervention that motivates people to get to a healthcare provider and receive this shot. The benefits need to outweigh the risks and any barriers need to be broken down.

The product is clearly the HPV vaccination. Presently, the price is expensive, costing $360 for all 3 doses. However, many private and public sectors cover the vaccine. Most girls are covered by private insurance, but for those who are not Vaccines for Children, Immunization Grant Program, Medicaid, and State Children’s Health Insurance Program are options to get the vaccine covered. Several states offer free or low-cost vaccines for girls who are not covered by any of the above-mentioned options (6). Cost is one of the most common perceived barriers (1, 12, 13, 14). To break down this perceived barrier, this campaign needs to directly address the price of these shorts and give information about insurance coverage. The easier it is for the patient the more likely she is to receive the vaccine.

The place for HPV vaccinations is technically throughout the world, but this campaign will focus on the United States. The campaign will be nationwide, but will specifically address at-risk populations and areas and provide tailored information for these communities. The campaign will include and emphasize information about where local health centers are located to get these shots. This emphasis on available locations aims to make it easier for individuals to access the vaccinations.

Promotion is how the health behavior is marketed to the public, including the product, price, and place information. HPV vaccinations are going to be promoted by healthcare providers and through our campaign. The campaign will be both media and print. IT will provide brief basic HPV knowledge, however, that is not what is currently needed for behavior change. Instead it will be based on having an effective messenger, telling people’s stories, and showing families who have received the vaccine. A main strategy when considering our product promotion is to appeal to core values. Core values are people’s deepest aspirations– freedom, control, justice, love, etc. These create mass appeal. Social marketing is about the consumer driven and not expert driven market. The campaign needs to find consumers who are willing to share their stories to others, to show them the benefits of the HPV vaccination (24).

Using this marketing mix of the 4 P’s, social marketing can help increase HPV vaccination rates.

Support 3: The New Messenger

An important hinge of social marketing, and integral to both parts of this intervention, is the messenger. Currently, the pro-HPV vaccination campaign lacks a central messenger and the public does not trust the two prominent faces for pro-HPV vaccination.

This new intervention needs to focus on the messenger, message delivery, and the public reaction. The goal is to increase vaccination rates and to do this parents need to know that receiving the vaccine is in the best interest for their daughter’s health. Although this can be done through statistics and study results, scientific evidence must be present in all health campaigns, we need a messenger that the public likes and trusts (22). Presumably parents and children/adolescents already see a healthcare provider that they like and trust. Parents and children/adolescents should also have common goals as their healthcare provider– hopefully the intent to work toward the best health for the child. So these traits– likeability, trustworthiness, and working toward the same goal– need to be embodied by a messenger. For this campaign, however, the messenger needs to appeal to a broad audience.

In this area, the pro-HPV vaccination campaign should look at and learn from the anti-vaccination movement. The anti-vaccination movement has found an effective messenger in Jenny McCarthy. She is a celebrity and she has a child with autism. Jenny McCarthy blames vaccinations for her child’s autism. She is has all of the traits of an effective messenger–likeability, trustworthiness, and working toward the same goal as parents (trying to keep her child healthy)– but most importantly, she has a personal and emotional connection and a story to tell. Not only should effective messengers embody these traits, they also appeal to the public because they have a personal connection and a moving story. In addition, because she is a celebrity, her voice is heard and her pictures appear in the media, giving further propulsion to her anti-vaccination message.

Although celebrities can be a powerful voice in the community, currently only about 26% of parents placed at least some trust in celebrities touting vaccine-safety information. However, 73% of parents placed at least some trust in other parents who say their child has experienced a negative effect from a vaccine (8). Jenny McCarthy is a celebrity, but what gives her message weight is that she is a parent. This intervention should take advantage of the latter statistic and have parents inform other parents about why they chose the HPV vaccine for their child. Between information from other parents and information from healthcare providers, this campaign should be ell equipped to deliver its pro-HPV message.


We have to create a movement based on people’s core values. It is not about selling a behavior; it is about creating a movement and setting a new standard for health. The pro-HPV vaccination campaign needs an overhaul. Currently it does not have an effective messenger, is based on an inappropriate model to create health behavior change, and does not address parental concerns or other important factors because it is an education only approach. But if these flaws are fixed– if we can find an effective messenger whether it be healthcare providers in local communities or an outspoken celebrity, if we make sure healthcare providers are having these immunization conversations with patients, and if we utilize social marketing– then we can successfully increase the acceptability and adoption rate of the HPV vaccination.


1) Reiter, P. Brewer, N., Gottlieb, S. McRee, A. & Smith, J. Parents’ health beliefs and HPV vaccination of their adolescent daughters. Social Science & Medicine 2007; doi:10.1016.

2) Centers for Disease Control and Prevention. 2010 Sexually Transmitted Disease Surveillance. Atlanta, GA: Centers for Disease Control and Prevention, 2010.

3) Centers for Disease Control and Prevention. Genital HPV Infection- Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

4) Giacobbe, A. A Drug Double Standard. Boston Globe Magazine, 11 Dec 2011.

5) Centers for Disease Control and Prevention. 2010 NIS- Teen Vaccination Coverage Table Data. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

6) Kaiser Family Foundation. Fact Sheet: Women’s Health Policy Facts. CA:, Feb 2008.

7) Caskey, R., Lindau, S., & Alexander, G.C. Knowledge and Early Adoption of the HPV Vaccine among Girls and Young Women: Results of a National Survey. Journal of Adolescent Health 2009; 45, 453–462.

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15) Centers for Disease Control and Prevention. Preteen and Teen Vaccines: CDC Preteen and Teen Vaccine Communication Campaign. Atlanta, GA: Centers for Disease Control and Prevention, May 2011

16) Gardasil.

17) Dempsey, A. F., Zimet, G. D., Davis, R. L., & Koutsky, L. Factors that are

Associated with Parental Acceptance of Human Papillomavirus Vaccines: A Randomized Intervention Study of Written Information about HPV. Pediatrics 2006;

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18) Kotz, D. Rick Perry’s HPV Vaccine Misstep: The Real Problem was His Conflict. 2011.

19) Cooper, L.Z., Larson, H.J., Katz, S.L. Protecting Public Trust in Immunization. Pediatrics, 2008; 122:149-153.

20) Reinberg, S. CDC Report Finds Adult Vaccination Rates Still Lagging. HealthDay News 17. Now. 2010.

21) University of Washington. Models of Social Communication. Department of Speech and Hearing Science, 2001.

22) Opel, D.J., Diekema, D.S., Lee, N.R., Marcuse, E.K. Social Marketing as a Strategy to Increase Immunization Rates. Archives of Pediatrics and Adolescent Medicine, 2009; 163(5):432-437.

23) Healey, B. & Zimmerman, R. The New World of Health Promotion: New Program Development, Implementation, and Evaluation. Sudbury, MA: Jones and Bartlett, 2010.

24) National Cancer Institute. Theory At a Glance. US Department of Health and Human Services, 2005.

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