Tuesday, January 1, 2013

HPV Vaccine: Getting Young Men In On It Using Social And Behavioral Science Theories– Mary Buckley

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States and a known risk factor for oropharyngeal and anogenital cancers, especially cervical cancer. The US Food and Drug Administration approved Gardasil for HPV vaccination in 2006. Gardasil protects against four strains of HPV, two of which cause about 70% of cervical cancer while the other two cause about 90% of anogenital warts (1). There is enormous public health potential for reduction in negative outcomes associated with HPV infection if a large enough number of young people are vaccinated and are no longer able to acquire or transmit infection to sexual partners. Individual immunity is important, but a large enough population vaccination provides protection to those who are still susceptible. Thus, regardless of individual risk, vaccination decreases the greater risk of the general population (2)(3).  
The FDA initially approved HPV vaccination for use among young women, recommending that young women age 11-12 be vaccinated, with catch-up vaccination recommended up to age 26. The idea is to have women vaccinated long before their first sexual encounter and, in doing so, prevent future cervical cancer caused by infection. However, in 2009, Gardasil was approved for use in boys and young men age 9-26 (4) and is now recommended by the Centers for Disease Control and Prevention (CDC) for young men between the ages of 11 and 12 with catch-up vaccination recommended up to age 21 (5).
The CDC currently provides educational information on their website and in pamphlets regarding HPV in both men and women. Since the age recommendation for vaccination is 11-12, much of the information provided by the CDC is directed toward parents. However, there is information that is geared toward young adults who are learning to make their own health decisions. Furthermore, young adults will receive this information from their primary care physicians who will recommend vaccination if it has not already been administered. This paper will focus on the age group of young adults, specifically the target audience of young males for whom HPV vaccine was most recently recommended. There is no formal “campaign” directed toward this audience, but this paper will critique the current model of recommending HPV vaccination to young men. 
Critique 1: Public Health Paradigm In Marketing
            The CDC’s current marketing of the HPV vaccine (both for young men and for young women) employs the traditional public health paradigm by using the core values of health and safety. Although heath and safety are strong core values for those working on public health campaigns at the CDC, they are not the ultimate core values of the general public, especially not of the audience of young males to whom the CDC is trying to “sell” the importance of HPV vaccination. The CDC presents “fact sheets” that provide information specifically for men (6) and general information about the vaccine and dangers of HPV infection for both genders (7).
             According to the CDC’s information, men should receive the HPV vaccine to prevent genital warts and cancers of the anus, penis, and oropharynx (6). However, a majority of the general information on HPV vaccine focuses on prevention of cervical cancer. Cervical cancer is the second most common cancer among women worldwide and its burden is strongly associated with socioeconomic disparities (1). Although cervical cancer caused by HPV is certainly a major public health concern, the use of cervical cancer prevention as the means of promoting vaccination excludes the male audience.
            To maintain use of the health core value in promoting HPV vaccination among males, the CDC provides a lot of information about the serious health effects of HPV infection experienced by males. As mentioned above, these health effects include some types of cancer in addition to genital warts. Gardasil protects boys and men against most types of HPV that can cause anal cancers and genital warts. However, the CDC fact sheet goes on to express how uncommon these health problems are among straight men and men who are immunocompetent (6). So, even if men are concerned about the health problems associated with HPV infection, they are unlikely to be motivated to request HPV vaccination solely by reading this information on a fact sheet. They might actually be dissuaded from vaccination upon learning that they are not among a group that can be seriously affected by HPV infection.
            Menashe and Siegel describe the importance of a strong frame and use of framing theory in their article “The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues – United States, 1985-1996.” Although their article discusses the framing battle between tobacco companies and tobacco control organizations, the concept of framing theory applies to any public health campaign. When developing a frame, core values other than health are much more compelling. Tobacco companies have been successful for so long because their campaigns consistently target very strong, human core values such as personal freedoms and civil liberties (8). These core values have kept the tobacco companies’ argument relevant despite the ever-growing wealth of information about health implications of smoking and tobacco use. As seen in the case of HPV vaccination, the core value of health does not hold up amid changes in vaccination recommendations.    
            Furthermore, appealing to the core value of health provides a platform for arguments about vaccine safety and potential side effects or risks associated with HPV vaccination. Regardless of gender, an argument exists regarding the safety of vaccines. The CDC’s fact-sheet for men directly addresses this concern by referencing the many successful studies carried out to determine the safety of Gardasil in both men and women. Researchers have not found any serous adverse events associated with HPV vaccination (6)(7). However, the concern about adverse events often gains a great deal of media coverage when it is brought up. Therefore, the health core value can be taken away from the vaccination campaign and used against it in an anti-vaccination argument about dangerous side effects.
            Social marketing has gained a lot of popularity among public health organizations and public health campaigns are using commercial marketing concepts to promote behavior change. In their overview of the use of social marketing in public health promotion, Sonya Grier and Carol Bryant describe the importance of offering benefits that the consumer (not the public health professional) truly values when developing a marketing strategy (9). As such, the most important aspect of marketing is researching what it is that people want most and then using that information to “package” the product in ways that fulfill those deepest desires. The CDC does two things in its HPV vaccine promotion that contradict the recommendations of Grier and Bryant. With health as a core value, young men who choose to be vaccinated against HPV will generally not receive a valued benefit in return for their decision. Health information about HPV does not touch at the deepest held values of young males in the United States. Additionally, the HPV vaccine campaign does not take into account the fact that it is not possible to simultaneously appeal to all types of people. Successful social marketers know “it is not possible to be ‘all things to all people’” (9). The CDC’s information sheets are not making use of marketing to the values of the specific population of interest. The “HPV and Men- Fact Sheet” has images of happy young men and provides information specific to the gender, but the message is not packaged in a way that appeals to their values.
Critique 2:
            In addition to the weakness of the core value around which the HPV vaccine message is developed, the way in which that message is given to its audience violates communications theory. Communications theory holds that the context of a message affects how persuasive that message is to its audience. The message about HPV vaccination being given to young men is not likable and does not have positive associations. When and where people encounter a message is crucial to how they respond to the information.
            In their 1965 paper “Facilitating Effects Of ‘Eating-While-Reading’ On Responsiveness to Persuasive Communication,” Janis et al. describe the tendency of people to yield to persuasion when they are engaging in a gratifying activity.  Their experiments focused on changing opinions of study participants (undergraduate students) given persuasive written communications in the setting of eating free food or no food (10). When students were eating, they were more likely to accept the messages that they were given. These study results were significant, but certainly did not elucidate a novel concept. Salesmen, businessmen, and lobbyists often use the same strategy when they “soften up” clients (10). They present their message to clients around a dinner table or at a café rather than in a conference room or office. The HPV vaccine promotion fails to take this strategy of persuasive communication into account. The CDC provides information to young men in the form of health pamphlets that are normally distributed at health care centers. Also, much of the information provided by the CDC is geared toward medical professionals who are encouraged to bring it to the attention of their patients. A doctor’s office is not an environment that is often associated with gratifying experiences. In fact, a doctor’s office may have the opposite effect because of the association with illness.
               In her chapter “Thinking Positively: Using Positive Affect When Designing Health Messages,” Jennifer Monahan describes “heuristic appeals” as the “first step in enhancing the likelihood that individuals will engage in thoughtful processing” (11). So, unlike the Janis et al. experiment affecting students’ acceptance of messages at one point in time, Monahan emphasizes that repeated exposure to the positive heuristic cue leads to a positive feeling toward the message (11).  HPV infection is not something that necessarily affects most people’s everyday lives, so it would make sense that young men would not seek out and evaluate information on HPV vaccination. Therefore, only receiving information from a doctor or in a health information setting can make the initial association with the message negative or, at best, neutral.
            A primary exposure to a message that can be associated with a mood or feeling influences subsequent decisions related to that message. The CDC does not take advantage of the possibility to harness the primary exposure and associate it with a positive mood or feeling.
Critique 3:
Not only does the CDC choose the wrong setting to communicate the message to young males, but also the person delivering the message violates the communication theory concept of similarity. The HPV vaccine message to young men comes primarily though patient/health care provider counseling. Therefore, there is a lack of similarity between the messenger and the target audience that can foster psychological reactance. Psychological reactance emerges when individuals feel that their freedom is threatened. Social psychologist Jack Brehm, who developed the theory, explains that when people sense a threat to their freedom, they try to reestablish that freedom by acting in the opposite manner of that being directed (12). Although it might not seem as though doctors are threatening the freedom of young men regarding HPV vaccination, the message coming from a person of authority does create reactance in an audience. Young adults like to consider themselves “worthy of determining their own health outcomes,” and they receive numerous messages “prescribing and prohibiting many of their prospective behaviors” (13). So, the doctor-patient conversation about the benefits of HPV vaccination could have the opposite effect of that desired by proponents of vaccination. Young men might seek to restore their “threatened freedom” by refusing vaccination solely on the basis of the messenger. 
Paul Silvia’s research on reducing resistance identifies similarities between messenger and audience as a way to reduce or “deflect” reactance (14). Silvia’s experiments found that interpersonal similarity reduces resistance even in the context of a threat to freedom. A threatening message given to his undergraduate research participants by a similar communicator was still persuasive despite jeopardizing freedom. In these experiments, similarity was as simple as a shared birthday, first name, gender, year in school, or shared values reported on a scale of importance (14). However, the CDC does not take this importance of similarity into account in its promotion of HPV vaccination for young men.
It is probably difficult for young men to establish similarity with their physicians and, although there are pictures of young people on information brochures, those young people are not the ones providing the message. For example, one CDC HPV brochure contains five pictures of young people (both men and women) with tattoos and dressed in sexy, age-appropriate clothes. Most pictures portray couples in intimate positions. It is possible that young men relate to the individuals in these pictures; however, none of the pictures show peoples’ faces (15). This stylistic choice might have been made for a reason, but it makes it difficult relate to the people in the photographs. It also makes it especially challenging to establish that these young people are the ones giving the message detailed in the brochure. Therefore, including these pictures does little to reduce psychological reactance.
Suggested Intervention
            I suggest that the CDC invest in a targeted advertising campaign promoting HPV vaccination in young males. Although there are literature and brochures available for young men, there is no effective communication that frames the topic favorably for this target audience. The recommendation for male HPV vaccination is relatively new and is preceded by the recommendation for young women as prevention of cervical cancer. So, understandably, there has not been the same amount of time and research invested in promotion of vaccination for young males. However, their vaccination is crucial in the development of herd immunity to HPV strains that cause cancer and genital warts. The message needs to reach young males outside the context of a health care setting. Although an advertising campaign for HPV vaccination among women exists, it cannot be tailored to “fit” the young male population. An entirely new advertising campaign is required that makes use of extensive research of the target audience, associating the message with a positive mood or feeling, and communication through people who establish similarity with the target audience. 
Intervention 1: Research The Target Audience
            To develop an effective marketing strategy for HPV vaccination among young men, the CDC needs to appeal to a stronger core value than that of health. It is important to provide specific information about disease and health, but investing in research for a marketing campaign could make the target group much more receptive and reach those people who would have had no interest in reading or talking about HPV. Investing in research about the values of the target group would involve developing an understanding of the target audience’s “needs, aspirations, values, and everyday lives” (9). Grier and Bryant suggest that such research does not need to be expensive or complex. Consumer data may already exist for that target audience. Also, it can be beneficial to involve consumers (young men) as partners in the planning process.
            A great example of successful marketing research for a  young adult audience is the “Truth” campaign that effectively reduced youth tobacco use in Florida between 1998 and 2000 (16). This campaign had a lot of money available to afford cutting edge marketing resources (17), but the same strategy can be successful in any public health campaign. The marketing team for “Truth” spent a great deal of time on research and conducted hundreds of interviews with members of their target audience (17). Thus, they were able to develop a youth-guided marketing campaign with an effective “brand” for anti-tobacco.
            One very important aspect of marketing theory that “Truth” addressed is focusing the message and not trying to apply it to too broad of an audience. It can be tempting to use resources to try to develop a marketing campaign that reaches the largest number of people, but this is not the intention of marketing. It is important to establish the specific target group and let research on that group dictate the direction of the marketing campaign. Therefore, an HPV vaccine marketing campaign needs to be developed for young men independent of a campaign for young women or parents. This may seem obvious, but having different campaigns does not just mean different literature. It requires targeted research and the creation of a marketing team with input from the intended audience.       
In their study of motivations for exercising, Segar et al. look at the connection between goals and behavior. Women in their study were more likely to adhere to exercise goals related to daily quality of life than healthy aging, despite reporting equal value attributed to each. Segar et al. affirm, “immediate payoffs motivate behavior better than distant goals” (18). So, an HPV vaccination marketing message needs to appeal to young men with a core value that is stronger than health and promise to fulfill the immediate goals associated with that core value.
Intervention 2: Associate The Message With A Positive Mood
            To effectively utilize communication theory for HPV vaccination, the CDC needs to find a new context for the message. When, where and with what associations the topic is addressed all need to be taken into account. Taking the message of HPV vaccination for young men outside the doctor’s office would be the first step in this intervention. Finding a setting in which it would reach young men while they are in a favorable mood is the key. Not all of the information that is covered in the CDC’s brochures needs to be included in the advertisement message. It is most important that the audience is primed to consider the topic in a favorable light.
            Television and radio advertising provide a great way to reach the target audience outside the health care context. Advertising time slots during sporting events can take advantage of a positive mood, especially for the target audience of young men. Considerable funding behind the Florida “Truth” campaign allowed them to run advertisements on channels and at times with high teen viewership like on MTV and during broadcasting of the Superbowl (17). But even without significant funding, one can develop an advertisement that creates its own association with a positive mood. Monahan writes that heuristic appeal can come from the use of a popular song or visual imagery, providing a cue for positive feeling toward the message (11).
                Gerald Gorn conducted experiments to determine the relationship between hearing liked or disliked music and product preference (19). Apart from just music, his study question is whether or not “background features” of advertisements affect attitudes. His results indicate that the presence of “liked” music can cause people to choose a certain product when there is very little product information provided (19). Gorn mentions that people are often exposed to commercials when they are not considering buying the advertised product, and it is in those situations that background features are most important. In the case of HPV vaccination, young men are not considering the “product” of vaccination, so product information is not as influential as background stimuli that can arouse emotion. Very little specific information about HPV actually needs to be in the advertisement because such information will be presented by a physician once an individual has developed a positive attitude toward the “product.”
Intervention 3: Establish Similarity
The  “One Less” advertisement put out by Merck, the pharmaceutical company that makes Gardasil, is a good example of establishing similarity between the messengers and the target audience. Merck’s “One Less” campaign has designed its website to include pictures of young men since Gardasil is now recommended for them (20), but the advertising message is still directed toward young women. The same advertising campaign cannot be tailored toward young men because the message specifically empowers women to be “one less” statistic of cervical cancer (21). However, the use of similarity in this advertisement is a good example of a way to reduce reactance. The advertisement starts out with a young girl skateboarding. She says that she could be “one less” woman to learn that she has cervical cancer. Other young women join in with the same statement while they are playing basketball, horseback riding, playing drubs, and dancing (21). The people portrayed effectively identify with strong, independent young women. The target audience of the advertisement will likely find interpersonal similarity with these young women and identify them as embodying ideals of their age group.
An HPV vaccine campaign for men could benefit from a similar approach. The focus of an advertisement would be young men engaging in activities to which their audience can relate while providing their own reasons for receiving HPV vaccination. The primary goal in the development of the advertisement would be to make the actors likable through similarity. Silvia writes that similarity “creates liking” which is the “positive force towards compliance” (14). Rather than coming from a doctor or health care provider, the message would be from a more likable figure who would not inspire the same reactance. 
            There are certainly challenges facing the CDC in any HPV vaccination campaign targeting young men. As I mentioned before, the CDC does not currently have a formal HPV vaccine campaign for men, nor does the pharmaceutical company that produces Gardasil. However, the CDC does provide a good amount of information (in the form of brochures and recommendations for physicians) intended to motivate young men to get vaccinated. An advertising campaign by the CDC could make young men more receptive to information about HPV vaccination. However, HPV vaccination affects men differently than it does women; so, consumer research and effective use of communication theory will be crucial to successfully influence the vaccination decision of young males.    

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