Beyond Birds-and-Bees: A Qualitative Content Analysis of Online HPV Vaccination Communication

"The analysis of traditional and new media, including social media, offered a unique lens to explore the diffusion of online messages about HPV vaccination..."

Health communication campaigns increasingly utilise multimedia strategies and social media to increase knowledge, awareness, and vaccination uptake. This study applied the diffusion of innovations theory to explore online HPV vaccination messaging at the local, regional, and statewide levels in South Carolina, United States (US), which has the lowest rate of human papillomavirus (HPV) vaccine completion among females in the US (30.8%) and is among the lowest states in the US for up-to-date vaccination among males (27.4%). The study included an evaluation of online messaging to identify potential approaches for reaching the intended audience with the goal of increasing vaccine uptake.

Diffusion of innovations theory provides a framework for exploring how behaviour change may occur to create more effective and targeted health communication interventions. According to E.M. Rogers, an innovation spreads over time through communication channels among members of a social system, who are classified into adopter categories: (i) innovators, (ii) early adopters, (iii) early majority, (iv) late majority, and (v) laggards. On this theory, adopting a new behaviour, such as HPV vaccination, is a process that includes the knowledge stage, persuasion stage, decision stage, implementation stage, and confirmation stage. In 2003, Rogers suggested that online traditional and new media, including social media, offer opportunities to diffuse information through personal and impersonal influence, which may be similar to or even greater than what is possible through mass media and/or interpersonal channels.

A qualitative content analysis of publicly available online documents in South Carolina between June 1 2014 and May 31 2015 was performed, including 83 website/blog posts, 211 tweets, 144 Facebook posts, and 31 articles in local and statewide newspapers. A total of 54 organisations presented HPV vaccine-specific content through these channels: statewide health care organisations (n = 29); school districts (n = 5); youth advocacy groups (n = 19); and parental groups (n = 1).

Findings are explored with illustrative quotes to explore emergent themes. Each theme was represented across all sources, including website/blog posts, social media posts, and articles. In brief:

• Relative advantage: Messaging in South Carolina emphasised the relative advantage of HPV vaccination as a cancer prevention strategy.
• Compatibility: Individuals and organisations expressed fear of increased sexual activity among adolescents. These messages explicated gaps in the vaccination's compatibility with the audience's existing values and needs. For example, a local healthcare organisation's website highlighted an article describing healthcare providers' concerns: "some pediatricians think that vaccinating means they'll have to go into a birds-and-bees discussion with an 11-year-old."
• Complexity: Messaging revealed difficulty with understanding and using HPV vaccination, including the number of decisions required to achieve vaccination, which may be complicated by misinformation. Despite the importance of practitioner support, several messages described barriers to full healthcare provider buy-in and advocacy for the vaccine.
• Trialability: News articles and social media posts showcased progress and gaps in HPV vaccination; peers may act as a vicarious trial for later adopters of the HPV vaccine.
• Observability: Individuals and organisations expressed fear of potential harmful side effects of the HPV vaccine. Analysis revealed scientifically inaccurate messaging that the vaccine could cause harmful, life-threatening side effects.
• Informed choice: Two clusters of social media posts emerged around the South Carolina Cervical Cancer Prevention Act. Messaging focused on informed choice for parents and increased access for underinsured and uninsured adolescents and young adults.

This content analysis has some implications for practice, including:

• Current online messaging emphasising HPV vaccination as cancer prevention serves as a fear appeal and has the potential to backfire. Health communicators should balance fear appeals with messages of empowerment.
• Messages should focus on compatibility with the intended audience's values by addressing concerns and emphasising that the HPV vaccine is an important and routine component of preventive health care.
• Messages should be tailored based on gender to address barriers to series completion among females and initiating the vaccine among males. Health communicators may consider messages emphasising the health consequences of HPV among men; communication aimed at women should include messages of empowerment.
• This content analysis highlighted the complexity of HPV vaccination; educating health care providers and securing support from these practitioners may provide an opportunity to normalise HPV vaccination as part of the routine vaccination series.

In conclusion: "Findings suggest that application of diffusion of innovations theory to develop online health communication may increase uptake and completion of HPV vaccination."