Challenging Dogma - Fall 2009

Thursday, May 20, 2010

Gardasil: Improving the Intention to Vaccinate Rate amongst the Targeted Population – Sonia Marwah

The Vaccination Sensation
Vaccination is perhaps one of the greatest public health success stories as seen by the reduced rates of infectious diseases. Since the introduction of vaccines, smallpox has been eradicated throughout the world, and wild polio virus is also near elimination. Although vaccines are the greatest weapons that exist to combat infectious diseases, no vaccine is 100% safe or effective (5). The propaganda for vaccination has become so effective that many parents choose to overload their children with any vaccine that becomes available, no matter the price or availability. For certain diseases, such as polio, measles-mumps-rubella (MMR) and hepatitis, vaccinations are mandatory. Today, many more vaccines have become available. However, these innovations have come with a price and their fair share of criticism. In television entertainer, Jenny McCarthy’s book Louder Than Words: A Mother’s Journey in Healing Autism, she makes the point that “Many people aren’t aware that in the 1980s our children received only 10 vaccines by age 5, whereas today they are given 36 immunizations, most of them by age 2” (19). McCarthy’s book, as well as other sources of scientific and clinical evidence, has shown that the MMR vaccine in particular may be linked to autism in children (9).
Despite this critique, Public Health experts note that vaccines generally work best when everyone gets them. The principle of "herd immunity" states that when more people are protected against a particular virus, the more likely it will disappear from the population (22). Cervical cancer is a serious mortal threat for women caused by a virus known as HPV (Human Papilloma Virus), and a public health threat to all populations. Almost all (more than 99%) cervical cancers are related to HPV. Of these, about 70% are caused by HPV types 16 or 18 (1-2). Approximately 20 million Americans are currently infected with HPV. Another 6 million people become newly infected each year. This virus is so common that at least 50% of sexually active men and women acquire HPV at some point in their lives. On average, there are 9,710 new cases of cervical cancer and 3,700 deaths attributed to it in the United States each year. Some types of HPV can cause genital warts, whereas other types can actually cause cancer of the cervix. HPV is passed from one person to another by skin-to-skin contact, usually through having unprotected sex, especially at a young age. Although many women may have HPV, very few women will actually get cervical cancer because the body is able to fight of the virus on its own. Pap Tests are a diagnostic tool to detect HPV. Although there is no cure for HPV, the abnormal growth of cells can be treated (2, 4-6). Gardasil, developed by pharmaceutical giant Merck & Co., is a vaccine used today to prevent certain types of HPV, specifically HPV 16, 18, 6 and 11. Gardasil was approved by the Federal Drug Administration (FDA) for girls and women aged 9-26 on June 8th, 2006 (23).
Gardasil’s “One Less” Campaign – A Fearless Strategy
On November 23rd, 2006, Merck announced the launch of an advertising campaign for the world’s first cervical cancer vaccine, Gardasil. The campaign, called “One Less”, intends to encourage girls and women aged 9-26 who are eligible for the vaccine to begin their vaccination series, yet continue to see their physician for a regular Pap Test and screening. The campaign focuses on a strong and positive message designed to empower girls and women to become “one less” person who will battle cervical cancer by featuring young women and girls engaged in a variety of activities -- playing soccer, shooting baskets, skateboarding, drumming, and dancing. (20). Although this campaign is well-intentioned, it does not send an effective message about cervical cancer, because the message is not fearful enough for young girls. Witte and Allen argue that strong fear appeals with high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses and reactance (25). The “One-Less” campaign, with its upbeat commercials and attractive website, does not make the targeted audience feel threatened enough by the possibility of developing HPV and cervical cancer. The advertising does not discuss the threat or severity of acquiring cervical cancer; instead, the commercials are overloaded with girls smiling, laughing and singing a catchy, rhyming tune. Dr. Michael Siegel and Lynne Doner Lotenburg have outlined two basic marketing strategies that Public Health should adopt. The first is to use market research to identify the basic needs, desires and core values of the target audience. Secondly, public health should sell basic values and reinforce these values by support with compelling, emotional stories, not merely statistics and data (21). The Gardasil ad effectively sells the core value of freedom to youth by sending the message that ‘if you vaccinate, you will free yourself of HPV and cervical cancer’. However, neither the ads nor the website offer any emotional stories of young women who actually have cervical cancer, and who may have been too casual about sex in their youth. The “One Less” campaign, and other forms of Merck’s advertising for Gardasil does seem to target mothers of young women effectively, but there is not enough done to inflict fear in the minds of teenage girls (18). Mothers are generally the figure head who will be able to consent their children to receive vaccination, and they are also the ones supplying the funds for the vaccination. Still, the promotional materials are not as effective as they should be to help girls understand the natural history, transmission and prevention of HPV, and the true meaning of living with cervical cancer. Therefore, the campaign does not follow the guidelines of an effective persuasive fear-based message, as concluded by Witte and Allen (25).
A false promise to protect
Gardasil’s “One Less” multibillion dollar campaign is designed to use highly strategic tactics to win over health professionals, state governors and legislators, and obviously, women who will potentially use the vaccine. However, marketing itself as “if you receive the Gardasil vaccine, you will be one less statistic of HPV and cervical cancer”, may in fact be giving false hope for women across the nation. Gardasil’s entry into the market represented the first time a vaccine could offer the hope of cancer prevention. Gardasil is not a cervical cancer vaccine, it is actually a vaccine for HPV, and this is not emphasized enough in Gardasil’s advertisements and promotions. Also, Gardasil’s ads emphasize the impact of HPV on cervical cancer rather than its role in causing genital warts, which is not as serious, but still a concern for girls and women who are sexually active. The “One Less” campaign cleverly creates an image that becoming vaccinated with Gardasil means empowerment – their “guard” against cancer. By letting their “guard” down about unprotected sex, and thinking “Now that I’ve received the vaccine and am protected from cancer, I can be less careful about my sexual encounters”, is creating a false sense of protection and greater exposure to other aggressive variants of HPV or other sexually transmitted infections (STIs) if sex becomes unprotected. One study highlights the results of highly active anti-retroviral therapy (HAART) on the sexual behaviors of persons with HIV/AIDS, and suggests that there is an increase in high risk sexual behavior related to the initiation of HAART (24). This association may be directly relevant to HPV vaccination. Teens may engage in this irrational thinking, and neglect the fact that there are many other harmful STIs/STDs for which Gardasil offers no protection. CDC research suggests that vaccine protection will last a long time, the question is: how long is a “long time”, and will girls believe they are protected for their entire lives? It is also still unknown whether booster shots will be needed to provide long-term protection against HPV infection beyond the initial vaccination (6). This suggests that in order to remain effective, women will need to monitor how long it’s been since they’ve received the HPV vaccine, and then go in again to receive another shot after ‘X’ amount of years to maintain immunity against immunity. Some women may fail to get that booster shot and subsequently forget they may no longer be protected from HPV.
Barriers for Gardasil Vaccine Acceptance
The widespread use of routine HPV screening and cervical cancer vaccines can be expected to decrease the mortality of cervical cancer worldwide (15). Nonetheless, despite the high prevalence of HPV infection in the population, many surveys have documented low levels of knowledge about the virus or its consequences. To a lay audience, this message may be confusing. One study found that despite the high prevalence of HIV infection in the American population, 70% of women had never heard of HPV and almost 90% had never discussed HPV with their health care provider. This impedes maximization of vaccine rates, especially when people don’t understand the exact anti-viral purpose of the vaccine (18).
Secondly, there are those parents who have specific concerns about their children receiving an STI vaccine, and this concern is not sufficiently addressed by Merck and Public Health in general. In a study of U.S. mother, 48% of participants reported they would likely to vaccinate a daughter under 13 years of age against HPV (16). There was higher intention to vaccinate daughters over the age of 13. This data was collected from a pool of nurses, who are considered more educated about the advantages of vaccination. The intent to vaccinate is not quite as high as it needs to be in order take advantage of a cancer vaccination that is out on the market intended to protect 70% of women from cervical cancer. This evidence contrast with the national recommendation to target 11 and 12 year old girls for vaccination. Much higher rates of intention are needed in order to prove Gardasil efficacious and create the “herd immunity” effect. One study exposed the five clusters of reasons that non-accepting parents, usually tending to be conservative or minorities, who did not want to vaccinate their daughters due to pragmatic concerns about effects on sexual behavior, specific HPV vaccine concerns, moral concerns about sexual behavior, general vaccine concerns, and denial of need (8). Opponents of the vaccine fear that by hearing about sex, and a sexually transmitted disease, young girls might be less likely to abstain and more likely to become sexually active (7). Mandating such a vaccine may be premature and insensitive to those who feel negatively towards the HPV vaccine. Although mandating the vaccine may reduce disparities, the voices of conservative groups must be heard and addressed to help reduce any confusion and send a more positive moral message. The resistance amongst states and parents to vaccinate may be attributed to the concern of increased chance promiscuity amongst these young girls. The idea of mandating “unprotected sex” as some conservatives would say, has been too premature and insensitive to those who feel negatively towards the HPV vaccine. The question also becomes, how far can the government intrude into a person’s privacy in the name of public health? (13).
Lastly, although immunizations can be a cost-effective intervention for disease by advancing the quality of lives, the cost of the HPV vaccine is exceedingly higher than other childhood vaccines. The HPV vaccine costs around $360 dollars, some girls and mothers believe this cost is worth the price of cervical cancer Prevention. Nonetheless, there is the population of women who are most vulnerable to HPV, but would be least likely to receive it because of the high cost, creating further chasms in health equity (18).
A Shift in Focus for HPV Vaccination Campaigns
Merck’s marketing of Gardasil does not effectively inform the teenage youth about the dangers of acquiring HPV. Results indicate that the vast majority of participants learned about Gardasil from television advertising, so the focus of altering media to improve campaign effectiveness should be on marketing via advertising. There is a lack of fear instilled in the campaign’s message. Hale and Dillard note that an “effective fear appeal must include a severe threat, evidence suggesting the target is especially vulnerable to the threat, and the solutions are both easy to perform and effective”. This campaign falls short of the recommendations of the fear appeal message construct. The nation’s youth needs more convincing information to be able to make decisions about vaccinations. Practitioners should also be aware of how different age groups react to messages in order to maximize effectiveness. A study by Friedman and Shepeard showed that knowledge of HPV is low across all age groups, regardless of gender, location, or ethnicity. Social marketing is a behavior change strategy that offers a promising, population-level approach towards maintaining consensus for immunizations and potentially increase vaccination rates. By using emotional, compelling stories coming from women who are living with cervical cancer, this may be able to capture attention and motivation change, as explained through behavior change theory. Emotion is an appropriate way to influence the target audience to achieve the desired goal of increased vaccination rates (10). This serves as a comprehensive approach to educating girls at all levels about the reality of HPV and cervical cancer, and also accurately portraying HPV risk in a manner that would simultaneously induce fear about acquiring HPV. This will take the spotlight off of attempting to induce fear about not receiving the vaccine for HPV, which is not effectively performed anyway in Merck’s “One Less” campaign. Before advocating and mandating a vaccine, Public health officials should collaborate with pharmaceutical companies, along with other sources, such as journalists, health educators, healthcare providers, and women's health advocates to ensure that future educational initiatives explain the complexity of the association of HPV and cervical cancer and to stress the importance of continued cervical cancer screening (3).
Moving towards a more accurate promise
In order for consumers to make a choice regarding the Gardasil vaccination, it is important for pharmaceutical companies to mention the importance of alternatives or supplementary activity to the HPV vaccine. Offering alternatives and supplements in a public health intervention will diminish the line between a false promise and what choices exist in reality that can reduce any chance of acquiring HPV. The various alternatives to the Gardasil vaccination include abstinence and regular Pap Tests. The Gardasil campaigns do not recognize these alternatives in their ads. This message of alternatives would be important information, particularly for conservatives to believe that safe sex or no sex is preferred to any vaccination used to reduce HPV infection. Although the Gardasil advertisements do recognize that “it is important to continue routine cervical cancer screenings”, the ads do not specify what is mean by “cervical cancer screenings” and how to obtain these screenings (14). Therefore, advertising should provide a more clear definition of what HPV is, how it causes cervical cancer, and that Pap Tests are used for cervical cancer screening. Advertising should also note that that Pap Tests are still effective, and should not be used an alternative to vaccination, but rather a supplementary activity that must be completed by a caregiver to eliminate the chance of getting HPV. This especially pertains to those who have already received HPV vaccination and believe they are in the clear for getting HPV. Research is still pending about whether a booster shot is needed, implying that the effectiveness of the vaccine may wear off. Thus, it is highly important to acknowledge that the vaccine is not a substitute for a routine visit to the doctor or safe sex. In addition to this, in order to prevent sexual disinhibition and the tacit consent for teens to engage in sex, it is important to provide strong guidance counseling in schools, at home and in doctor’s offices regarding the importance of maintaining safe sexual behaviors (12). For example, some studies suggest that sex education programs in schools are most effective to delay the initiation sexual encounters of when they are based on social influence approaches and social learning theory. School based sex education programs would be a good place to start empowering youth about the consequences of unprotected sex (17).
Optimizing Outcomes for Cervical Cancer
The nature of the Gardasil vaccine as a vaccine for an STI automatically creates a stigma that the young girls and women who receive the vaccine are sexually active or intend to be sexually active, and find the need to protect them because they are putting themselves at risk due to their behaviors. However, the vaccine does not necessarily need to be viewed in that light. In the future, vaccination campaigns should be more aware how the vaccine is framed and how this may influence how receptive the audience is to cancer prevention and control. For example, HPV advocates should emphasize the vaccine as a cancer prevention tool instead of marketing the vaccine for HPV and feeding into the negative emotions associated with STIs (18). Reframing HPV will also help alter the ideology of a conservative’s view towards an STI vaccine. A CDC study validated that focus group participants believed they were at low risk of contracting an STI and associated words such as “infidelity,” “promiscuity,” “shame,” and “divorce” with an STI (11). Although the idea that the vaccine may lead to sexual promiscuity among those vaccinated may have no effect on intention to vaccinate, the framing of the vaccination message still must be sensitive to conservatives in order to maximize vaccination rates. Therefore, reframing the vaccine as a cancer prevention tool can alleviate the social stigma associated with STIs. In addition to reframing, a reform in HPV and cervical cancer education is three-pronged. First, before educating the youth about the HPV vaccine, Merck should alter their campaign to blend the marketing of their product, along with empowering the youth with information about HPV. At the same time, marketing should emphasize what cervical cancer is and what it really means. Reform must also occur in order to combat the barriers of vaccination cost. The HPV vaccine is the most expensive of all recommended childhood vaccines. Those who are most impacted by the cost are women between the ages of 18-26, who are typically not covered by a subsidy program, and are most likely to be uninsured. Instead of mandating the vaccine itself, mandating statewide insurance coverage may make HPV vaccination programs affordable for the uninsured who are interested. Reducing the cost of the vaccine will make intention to vaccinate high amongst all age groups (18).

There are numerous reasons as to why HPV vaccination intention may remain low, even with Public Health, in collaboration with policymakers, providers, health plans, and pharmaceuticals are advocating improving HPV vaccination rates. There is room for improvement in the areas of inducing more fear into the campaigns directed towards young teens, providing a more accurate promise of protection for women, and addressing the barriers to obtain a vaccine. This paper argues that these factors can be remediated. To invoke fear, HPV vaccine campaigns, such as the ad depicted in Gardasil commercials should tell more compelling stories from women who actually have cervical cancer. Gardasil, and other HPV vaccine campaigns should also stress the importance of supplements to HPV vaccination, such as Pap Tests and abstinence for a more comprehensive approach to prevent critical cancer. Lastly, certain obstacles should be addressed in regards to HPV vaccination, such as making the vaccine more affordable, tailoring to the concerns of conservatives, and improving sex and STD education. Looking forward, providing HPV vaccination for boys and men may serve as another controversy, but the same tactics should be applied towards tailoring the vaccine to the opposite sex.
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