Policy mattersPolitical and News Media Factors Shaping Public Awareness of the HPV Vaccine
Introduction
In 2006, the U.S. Food and Drug Administration licensed a vaccine for the human papillomavirus (HPV) that prevents the strains of HPV that cause 70% of cervical cancers. Within months, states introduced legislation requiring the vaccine for girls, prompting intense media discussion and debate over the vaccine's merits and potential concerns (Colgrove, Abiola, & Mello, 2010; Haas et al., 2009). Politicians, health professionals, conservative groups, women's health organizations, and researchers competed to have their message heard in the news media (Fowler, Gollust, Dempsey, Lantz, & Ubel, 2012), as legislative discussions over HPV vaccine requirements, education, and insurance coverage unfolded after 2006 across more than 40 states (National Conference of State Legislatures, 2012). Political arguments over the HPV vaccine even played a role in the 2011 Republican presidential debates (Gostin, 2011). Despite its great public health value, the vaccine has not achieved uptake at recommended levels. According to the 2010 National Immunization Survey-Teen, 48.7% of 13- to 17-year old girls have received one dose of the vaccine, and 32.0% have completed the series (Dorell, Stokley, Yankey, Liang, & Markowitz, 2011). Estimates of vaccine coverage for adult women are even lower, ranging from 9% (Caskey, Lindau, & Alexander, 2009) to 18% for initiation (Dempsey, Cohn, Dalton, & Ruffin, 2011) and 1.8% (Rosenthal et al., 2011) to 10% for completion (Dempsey et al., 2011). Understanding the factors that contribute to these relatively low vaccination rates is an important priority for research.
When a public health issue becomes politicized, as the HPV vaccine has been, and news coverage is extensive and often focuses on conflicts and disagreements among politicians and medical experts, there may be consequences on the public's attitudes and behaviors. However, existing studies of the HPV vaccine have rarely considered individuals' political orientation or likelihood of exposure to media coverage, leading to an incomplete picture of the factors that influence public attitudes toward the vaccine. Research has demonstrated that HPV vaccine awareness is high overall, but differs across subgroups; Whites (compared with non-Hispanic Blacks and Latinos), women compared with men, and those with higher socioeconomic status have significantly higher awareness of the vaccine (Allen et al., 2010; Cui, Baldwin, Wiley, & Fielding, 2010; Gelman, Nikolajski, Schwarz, & Borrero, 2011; Hughes et al., 2009; Jain et al., 2009). No previous work has examined how awareness differs by political orientation, although the limited existing HPV vaccine-related research that has considered such factors suggests that parents who identify as liberals reported stronger intentions to vaccinate their sons (Reiter, McRee, Kadis, & Brewer, 2011) and that women or parents who reported being liberal or moderate, compared with conservative, expressed greater acceptance of the vaccine (Constantine & Jerman, 2007; Stupiansky, Rosenthal, Wiehe, & Zimet, 2010).
The news media are an important source of information about the HPV vaccine (Cates et al., 2010), with the potential to affect both awareness of and attitudes about vaccination. Research using experimental methods has shown that the way news articles frame the vaccine, such as portraying the vaccine's effectiveness (Bigman, Cappella, & Hornik, 2010), emphasizing whether the goal of the vaccine is preventing cervical cancer or other outcomes (Leader, Weiner, Kelly, Hornik, & Cappella, 2009; McRee, Reiter, Chantala, & Brewer, 2010), and highlighting the vaccine's controversial elements (Gollust, Dempsey, Lantz, Ubel, & Fowler, 2010), influences attitudes. However, limited research using observational data is available to identify the actual impact of the news media on HPV vaccine-related perceptions outside of a laboratory context. One previous study relying on self-reported survey data indicated that adults who reported more health-specific media exposure had greater gains in knowledge about the HPV vaccine over time; there was no such relationship with self-reported general news exposure (Kelly, Leader, Mittermaier, Hornik, & Cappella, 2009). In this study, we advance previous research by documenting the volume of HPV vaccine-specific local media coverage and linking it with individuals' reports of media use.
Research and theory in political science and communication are helpful to formulate general hypotheses about why political predispositions and the news media might influence awareness of a politicized women's health issue like the HPV vaccine, both independently and interactively. Two bodies of literature are highly relevant: Theories on the relationship of ideological predispositions to attitudes and theories of media effects. On the former, research demonstrates that political predispositions (e.g., how liberal or conservative an individual is) influence citizens' attitudes about a host of policy topics—from education to health care—even more than characteristics representing an individual's personal interest in that issue (Lau & Heldman, 2009). Political orientation has been shown to serve as a cognitive heuristic, helping people to form opinions on complex policy topics because they can rely on “cues” in the media (i.e., matching their political inclinations to the political stances publicized in news coverage) rather than coming to their own original interpretations of an issue (Kam, 2005). In the case of the HPV vaccine, news stories about the HPV vaccine often featured competing messages from both liberal and conservative advocacy groups presenting their side's policy prescriptions and implications (Fowler, Gollust, Dempsey, Lantz, & Ubel, 2012); furthermore, opposition to HPV vaccine mandates was justified with ideologically based arguments, including concerns about the sexually transmitted nature of the vaccine and general resistance to governmental intrusion on parental autonomy (Colgrove, et al., 2010). Given the high volume of these ideological cues in the news media, liberals and conservatives may have been more attentive to news coverage of this issue than those with more moderate beliefs, which could translate to different opinions (Zaller, 1992), as evidenced by ideological differences in perceptions of the vaccine (Constantine & Jerman, 2007; Stupiansky et al., 2010).
The second related body of research relevant to this issue is communication theory on media effects, which has shifted over the last few decades from considering the media as a unidirectional, uniform force shaping citizens' views to acknowledging heterogeneity in the effects of media based on individuals' predispositions and considering reciprocal effects between news exposure and political attitudes (Bennett & Iyengar, 2008). Some people will resist certain media messages to which they are predisposed to disagree by not selecting those media, or, if exposed, they will resist the message by counterarguing the premise or selectively incorporating some aspects and forgetting others (Iyengar & Hahn, 2009; Lord, Ross, & Lepper, 1979; Taber & Lodge, 2006; Zaller, 1992). In the increasingly politically charged discourse surrounding women's health issues in general (and the HPV vaccine in particular), where it is relatively simple for individuals to link their political beliefs with a publicized perspective on an issue, we expect that individuals of different ideological orientations may respond to the news media differently.
In this study, we use nationally representative survey data to examine the association between demographic, political, media, and geographic variables on adults' awareness of the HPV vaccine. Based on previous research, we hypothesize that women (compared with men) and those with higher education (compared with lower education) will be more aware of the vaccine. We further hypothesize that as a result of the ideologically-oriented content that was a component of media coverage of the vaccine, conservatives and liberals will be more likely to be aware of the vaccine than moderates. We also hypothesize that, as a result of the intensity of state-specific media coverage, those who had higher exposure to media will be more aware of the vaccine, and that those who lived in a state that considered a vaccine requirement for school-age girls will be more likely to be aware of the vaccine. Finally, we hypothesize that, because of the selection and filtering processes that characterize media effects related to politically-charged issues, the influence of media exposure on awareness of the vaccine will vary by individuals' ideological orientation.
Section snippets
Sample
The survey was conducted using the web-enabled KnowledgePanel, a probability-based panel designed to be representative of the U.S. population. Initially, participants are chosen by a random selection of telephone numbers and residential addresses. Persons in selected households are then invited by telephone or by mail to participate in the web-enabled KnowledgePanel. For those who agree to participate but do not already have Internet access, Knowledge Networks (now known as GfK Knowledge
Results
Study participants were roughly evenly divided by gender, and were diverse in age, education, and household income. Thirty percent were non-White; equal proportions identified their ideological orientation as conservative (36.9%) or moderate (36.7%), and 26% reported their ideological orientation as liberal. Sixty-five percent lived in a state that had introduced legislation to require the vaccine for school-age girls by the time of the survey (Table 1).
Sixty-nine percent of respondents were
Discussion
When examining factors that predict health attitudes or behaviors, past studies of the HPV vaccine have infrequently taken the political context into account. However, health issues are often politicized in media and policy discourse, with the HPV vaccine a prime example of this growing phenomenon. Research demonstrates that the public has increasingly polarized health-related opinions (Baum, 2011; Gollust, Lantz, & Ubel, 2009; Kahan, 2010). This polarization in attitudes can translate into
Implications for Practice and/or Policy
Our findings suggest that demographic factors like socioeconomic status and gender, political predispositions, and the informational environment are all important factors to consider when considering women’s—and the general public’s—HPV vaccine-related attitudes. Future research should assess whether similar factors are also associated with awareness, attitudes, and behaviors related to other highly controversial and politicized women's health issues, such as breast cancer screening, abortion,
Sarah E. Gollust, PhD, is Assistant Professor in the Division of Health Policy and Management at the University of Minnesota. Her research examines media coverage of and public opinion toward controversial health policy issues, including childhood obesity, the HPV vaccine, and mammography screening.
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Sarah E. Gollust, PhD, is Assistant Professor in the Division of Health Policy and Management at the University of Minnesota. Her research examines media coverage of and public opinion toward controversial health policy issues, including childhood obesity, the HPV vaccine, and mammography screening.
Laura Attanasio, BA, is a doctoral student in the Division of Health Policy and Management at the University of Minnesota. Her research explores the role of social factors in shaping women's reproductive health services use.
Amanda Dempsey, MD, PhD, MPH, is Associate Professor of Pediatrics, Children's Outcomes Research Program at the University of Colorado School of Medicine. Her research focuses on barriers to implementing recommended childhood and adolescent vaccines, including parental vaccine hesitancy and vaccination policy.
Allison M. Benson, BA, is a graduate of Wesleyan University where she worked as a Quantitative Analysis Center research assistant and tutor before graduating with a B.A. in sociology in 2011. She currently resides in New York City.
Erika Franklin Fowler, PhD, is Assistant Professor of Government at Wesleyan University and Co-Director of the Wesleyan Media Project. Her research focuses on political communication, examining the content and effect of media messages in both electoral and health policy spheres.
Support for this project was provided through data collected by Time-sharing Experiments for the Social Sciences (TESS), NSF Grant 0818839, and funding from Wesleyan University's Andrew W. Mellon Foundation Research Grant, the Robert Wood Johnson Foundation Scholars in Health Policy Research Program at the University of Michigan and the Robert Wood Johnson Foundation Health & Society Scholars Program at the University of Pennsylvania. We thank Paula Lantz and Peter Ubel for their contributions to this project, as well as the Wesleyan University Quantitative Analysis Center.