Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Not Just About Cervical Cancer, Not Just About White Women-Nora McElroy

Awareness about HPV, or human papilloma virus, has dramatically increased in the last five years as a result of several educational and pharmaceutical industry driven campaigns.  The result has been increased awareness of the release of a vaccine that protects against several varieties of HPV and bolstered efforts to inform women of HPV and its carcinogenic effects.  Various public service announcements specifically intended to educate women about the existence of HPV and its association with cervical cancer were aired before the release of Merck’s vaccine Gardasil.  The design of these campaigns has missed a significant portion of people affected by HPV: men, the poor, and minorities. 

            Human Papilloma Virus is the most common sexually transmitted disease in the United States (1).  At any given time 44% of women have HPV and over 70% will contract the virus at some point in their lifetime (2).  HPV is also responsible for 5.2% of the total world cancer burden, making it a significant source of cancer diagnosis and mortality (3).  It is clearly associated with a potentially terminal disease, but also can cause uncomfortable genital warts in both sexes and that may require surgical removal in women.  Though these campaign was designed separately, all have used the health belief model’s focus on negative outcomes, and therefore have all the weaknesses of the model (4).  The targets of ads, choice of outcome, and incomplete information does not educate the entire affected population and does not address barriers to prevention and screening of HPV.

            Though the media, women’s groups, and pharmaceutical marketing have been focusing on the causal association between HPV and cervical cancer the virus actually has several other health outcomes.  The most common symptom of HPV is genital warts, which can manifest in men and women (5).  If the lesions form on the cervix they are either frozen off or surgically excised.  Otherwise there is no treatment and the warts and virus eventually resolve on their own.  Unlike genital herpes, another genital wart causing disease, there is no treatment for HPV and the virus can be transmitted even if the infected man or woman currently has no warts (6).  There is also research linking HPV infection to oral cancers, but its carcinogenic link to cervical cancer is far better established (7).  Human papilloma virus is not just a women’s disease and interventions need to address equality of burden of responsibility and outcomes.

            Some of the earliest educational campaigns to spread awareness of the association between HPV and cervical cancer were television public service announcement campaigns.  They used the Health Belief Method, connecting HPV with a serious health outcome, to influence behavior.  “Tell Someone” was specifically targeted at women and encouraged them to tell their friends, family, and acquaintances that HPV caused cervical cancer.  The commercial also stressed that many women are already infected with and unaware of the virus(8).  Another PSA, for, similarly stressed the causal association between HPV and cervical cancer (9).  Finally when Merck released its HPV vaccine, Gardasil, it launched a massive marketing and educational campaigned called “One Less.”.  It encouraged young, white, active women to be one less person affected by cervical cancer by speaking to their doctor and getting vaccinated (10).  This also lacked insight into the women most affected by HPV infection and cervical cancer.  Poor and minority women carry more of the disease burden than Caucasians and may not have access or a trusting relationship with a physician who could provide them with more information, screening, and vaccination (11).

            The PSAs take the wrong approach to HPV awareness, prevention, and screening.  All three PSA fail to mention that HPV is a sexually transmitted disease and that both men and women are infected and susceptible to genital warts.  Each targets only women, though men and women are equally likely to contract and spread the virus.  Also black, Latina , poor, and rural women are more likely to be infected with HPV and develop terminal cervical cancer, and yet these PSAs target healthy, middle class, usually white women (12).  Finally the chosen outcome, cervical cancer, is so distant that logically young women are not likely to consider it a risk when having sex.  The creators of these PSAs expect women, often teenagers, to consider a very distant outcome and do not offer any acknowledgement or assistance with the barriers of access, trust, or discomfort of discussing sexually transmitted diseases.


Not Just a Women’s Disease, HPV as a Sexually Transmitted Disease


            A major flaw in all of the PSAs is that they do not address the transmission dynamics of HPV.  After viewing any of them, a woman would have high perceived susceptibility to the virus without any concept of how she was exposed.  Since it is possible to contract HPV multiple times it is important that everyone, men and women, understand it is sexually transmitted.  It is not constructive to convince women they may have a life threatening disease by providing incomplete or misleading information.  This only results in fear and confusion, which makes further education and maintaining trust difficult.  By framing their intervention this way the advertisers actually construct more barriers by raising fear and requiring that people find the time and resources to get their own answers.  Omitting that HPV is a sexually transmitted disease places all the responsibility for screening and prevention solely on women by ignoring half of the infected population.

            Though cervical cancer is a specifically women’s disease human papilloma virus is not.  In targeting all of the commercials at women and the mechanism of transmission the marketers miss half of the people infected with and responsible for transmitting the disease.  Information on the disease burden of HPV in men is not nearly as available as women and men are not routinely screened.  Despite the relatively minor consequences for men there is no reason not to educate them about HPV, since it can cause genital warts and no person wants responsibility for causing cancer. 

            Still the framing of these interventions of HPV as a women’s disease, and not as a sexually transmitted disease, limits its potential and does not address the gross disparity of responsibility placed on individual women.  In order to prevent HPV related symptoms and diseases the target of interventions cannot be just women.  Placing all of the responsibility on women is undue burden, and does not address infections in men.


“Ask Your Doctor”

Disparities in Disease Burden, Knowledge, Trust, and Access


            The campaigns repeatedly encourage women to speak to their doctors about the risks and ways to prevent HPV infection, however many women do not have access to or trust a physician.  The commercials primarily feature well-dressed white women, ignoring that more of the disease burden of HPV is shouldered by Latino and black women.  Geography and lack of trust are known predictors for not seeing a doctor regularly, either because of access, cost, or mistrust (14).  Despite a great deal of research showing higher proportions of HPV in poor, rural, and minority areas the interventions do not target any of these populations.

            Disease burden and lack of HPV awareness are more common in black and Latina women when compared to Caucasians (15).  However both the “Tell Someone” and “Make the Connection” campaigns predominantly feature white and middle class women and do not use any branding or social theory to engage the viewer.  As a result women who most need the information will not relate to the commercial and therefore not benefit from it.  The “One Less” commercials fare slightly better by showing younger women of various races participating in activities like skateboarding, double-dutch, and step, which would connect better with the audience.  However the advertisement also informs women that they need to talk to their doctor for more information about HPV, cervical cancer, and the HPV vaccine.  The women targeted are the most likely to not have regular medical care or trust a doctor enough to discuss sexually transmitted diseases.

            The topic of STDs can be very difficult to discuss without a great deal of trust and cultural/societal sensitivity (11).  By presuming that viewers have a regular physician, much less be able to discuss sexual behavior with them, these campaigns lose touch with many poor, rural, young and minority women who do not.  Not enough information is given about other ways for these women to learn about HPV or affordable screening.  Offering an information source where the caller remains anonymous or providing contacts for free local clinics might be a better approach to engage poor and minority women.


Cancer in Twenty Years, Or Sex Now?  The Reaction of Teens and Parents


            Aside from the lack of insight into the women affected by HPV these campaigns also choose to focus on a distant and very rare outcome of infection.  Though approximately 70% of cervical cancer is caused by human papilloma virus it takes about fifteen years and persistent infection with specific strains of the virus for cancer to form (2).  This is a very rare outcome and is not likely to sway young people from having sex, or convince them to use protection.  Even vaccination is not an option for many young women due to the high cost of Gardasil.  The HPV vaccine costs about one hundred and fifty dollars for the three shots that grant immunity to four strains of the HPV virus (16).  However this is not complete protection against cervical cancer because vaccines are not 100% effective and Gardasil only protects against the two most common carcinogenic strains of HPV (17).  Therefore women who have had the vaccine are at reduced risk for cervical cancer, but are not immune.

            The “One Less” Campaign also targets mothers, which perhaps is a more effective strategy than targeting teenagers.  Mothers are more susceptible because they want their children to have a long and healthy life, and therefore have an interest in protecting their daughters from HPV and cervical cancer.  However using cervical cancer as the focus of the campaign creates more fear than necessary since it is such a rare outcome.  Cervical cancer is a real and dangerous disease, but if regular screening and testing is made widely available, accessible, and affordable, it is curable.  Therefore it is unnecessary to scare parents about what might happen to their children.  Providing enough information, like how HPV is transmitted and prevented is responsible, would be more effective because it would allow parents to inform their children about the risks.

             Finally the campaign ignores certain aspects of the disease that are more immediate concern and would help build a better case for people to defend themselves against it.  The genital warts that are sometimes caused by human papilloma virus are very uncomfortable, and in women can require minor surgery to remove (18).  Though these symptoms could be difficult to discuss with a doctor and are only treated when present on the cervix they could be used to encourage men and women to use protection and be screened regularly for HPV.  Persistent genital warts are a high risk factor for cervical cancer.  Therefore an intervention that ties together the carcinogenic potential of HPV and the more immediate discomfort of genital warts could be more effective.




            Due to the serious nature of cervical cancer it is easy to see why it has been a major motivation for HPV education.  However these interventions must be carefully framed so more people get the message than upper and middle class white women.  While these women may be more likely to be screened or afford vaccination others are at equal or higher risk of infection.   These interventions also unfairly put all of the responsibility for prevention and screening on women, for a disease that is carried by both sexes.  How can a virus be contained when only half of the population is being told about it?  In order to effectively reduce HPV infections and increase screening these interventions need to be redesigned to provide more useful information and reach a much larger segment of viewers.



Using Social Marketing to Raise Awareness of HPV


            The past approaches have relied too heavily on the health belief model and tried to raise awareness by focusing on a very distant outcome.  A major problem with the health belief model is that it targets individuals, not groups of people (14).  However research shows that people tend to consider social opinions and norms when making decisions as well (15).  Instead of using an antiquated model that has been shown to be ineffective, the social sciences have other concepts that are effective at educating and changing behavior.  Though the first two campaigns were based entirely on the health belief model, the “One Less” campaign begins to blend behavioral science with the health belief model.  The slogan “One Less” is a form of branding, which is a component of marketing theory.  Social marketing is an excellent way to reach a large audience, and account for social norms and opinions.  Four major components are required for an effective social marketing intervention: product, price, place, and promotion (16).  Using these four components an initiative that addresses the weaknesses of the previous interventions can be created.

            As has already been discussed, place and product have been poorly targeted in HPV education campaigns, having focused on white women with more access to physicians, instead of the populations most at risk.  They also ignored that men are also carriers and transmitters of the disease, a key fact in slowing the spread of HPV and its other associated cancers (17).  A new television advertisement using marketing theory can fill these holes, educating men and women about the immediate and distant effects of HPV, while offering help to those without resources for prevention or screening.   The product offered will be confidence from being informed, placed on television screens, which is a common part of the lives of most American teens, and promoted by high circulation during shows popular with teenagers.  It will also address the price by offering free information and access to HPV and cervical cancer screening.

            The new commercial opens with two black teenagers cuddled in front of a television.  In a warm colored room two black teenagers lean against a wall, the boy says: “You’re cool, you know how it works, and you’re in charge.  So why do people want you to think that only women need to think about HPV?  Human papilloma virus is sexually transmitted: that means both men and women get it.”  The young woman adds: “Don’t think just because you don’t have cervical cancer, or a cervix that, you don’t need the facts.  HPV causes genital warts in men and women, as well as several cancers, don’t sweat it, be smart.”  Meanwhile images of teenagers in classrooms and walking down an urban street flash across the screen.  The young man: “Take charge, condom use, vaccination, and abstinence all can reduce the spread of HPV.  And all HPV related cancers are treatable with regular screening.”  Finally the young woman concludes: “Knowledge is power, take control, get informed, get tested for HPV, and get tested for cervical cancer.  Call this number for more information and free, confidential testing and treatment for HPV, genital warts, and HPV related cancers.”


Bringing Men into the Equation


            A glaring omission in earlier interventions has been that HPV is a sexually transmitted disease carried by both men and women.  The new intervention intentionally features a young man and woman to counter the perception that only women need to worry about HPV.  A key part of marketing theory is offering an aspirational image to the consumer (18).  Both teenagers in the new commercial are confident, relatable, and informed, encouraging viewers to be like them and get informed.  Building on the knowledge disseminated in the other widely distributed commercials, it explains that HPV also causes genital warts.  Providing simple education greatly increases awareness of HPV risks and outcomes among young adults (19).  A simple change in the old method, including men and women in the commercials, broadens the audience.

            This demonstrates several improvements over the other commercials.  Men would have had no interest in the earlier commercials, since they stressed the link to cervical cancer.  Though men may worry about cancer in their wives or children, a young man is not likely to consider cancer an outcome when having sex and likely needs a more personal risk to consider changing behavior.  Gender based research shows that men and women may require different approaches to some public health issues (20).   Additionally, the intervention appeals to young men and women’s desire for self-dependence and independence. By implying that being informed and protecting themselves and others against HPV makes you in charge and in-the-know, youth are sold the image of a strong and mature self.


Reaching Out to High Risk and Uninsured Populations


            Another key component of the product offered in the new intervention is featuring young people of color, particularly black, so the intervention reaches the people most likely to contract HPV.  Despite starring black students the commercial could target more people since the actors are the same age as the students at risk for their first HPV infection.  Again the image of confident, independent teens offers an ideal that viewers can achieve by using the information offered (18).  The new intervention also makes information, treatment and screening more available by offering a number to call, instead of informing viewers to speak to their doctors.  It promises confidential and affordable options, which hopefully would encourage people without health insurance or routine doctors visits to call.  Addressing the price of seeking information and screening is vitally important because the populations most in need of aid are poor, without insurance or regular health screenings (21).

            Both of these are improvements over the older commercials.  By offering a strong identity to youth the campaign attracts attention and sidesteps any stigma around talking about or getting tested for a sexually transmitted disease.  And, unlike the other interventions, the psychological and monetary cost of HPV screening is acknowledged.  Offering a toll free number allows young people to get more information without needing to see or trust a doctor.  Also the commercial stresses confidentiality and free screenings, these are necessary for the success of the intervention (22).  Doctor’s appointments and vaccinations are very expensive and not affordable for portion of the US population.  Free screening, discounted vaccinations, and aid in finding affordable treatment help control the costs, unlike the other commercials which provided no information of making screening and preventative measure accessible.


Not Everyone has a Cervix, But No One Wants Genital Warts!


            Genital warts are an outcome that which it far more likely to attract male attention than cervical cancer because it is a symptoms they can have themselves.  As the young women said: men don’t have cervixes, why should they care?  By providing an outcome that is relevant to the entire population that carries the disease the commercial will reach a more homogenized audience (23).  In women these warts can require surgical removal and there is no treatment for men except to wait for them to resolve, and have a far shorter latency period than cervical cancer (21).  Providing this information to young men and women may encourage them to choose safer practices like using condoms.  Since the intervention is targeted at a susceptible population it will also encourage them to learn more about HPV and give access to screening and treatment.  It’s important in this intervention to attract attention with the product of being informed and prepared, but also educate so the audience understands why preventing HPV infection is important.

            Many social and behavioral intervention models, such as the health belief model, involve a weighing of the perceived risks against various social and physical barriers against change (24).  Raising awareness for a different outcome of HPV infection the new intervention stresses another, more immanent result.  All the earlier interventions repeatedly stressed a cervical cancer which takes 15 or more years after infection with HPV to become detectable.  Twenty years is a very long time in the future for a teenager to consider when having sex (25).  Other STDs that affect more people, like HIV, herpes, or Chlamydia attract more attention because of their unpleasant or lethal outcomes that come shortly after infection or are chronic once contracted.  By choosing a more immediate outcome of HPV the new intervention improves the chances that teens may consider taking actions to prevent infection or gets screened for HPV and related cancers.




            The intervention outlined above addresses a number of the weaknesses of common HPV awareness and prevention campaigns.  By integrating social marketing concepts and building on the awareness that the other commercials spread.  The inclusion of men, and low income, uninsured blacks ensure that the education campaign will reach more people.  In addition the new intervention offers help getting and paying for screening for HPV related diseases, another measure to reduce the vulnerability of marginalized population to HPV.  Finally the new commercial stresses that genital herpes is an outcome of HPV infection, a more immediate outcome for women and relevant one for men.  The combination of these changes make the new intervention better at reaching the people that most need education about the risks of HPV.




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