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1 KNOWLEDGE, BELIEFS, AND ATTITUDE S ABOUT THE HUMAN PAPILLOMAVIRUS VACCINE AMONG FEMALE CO LLEGE STUDENTS: DOES MASS MEDIA EXPOSURE INFLUENCE VACCINE ACCEPTANCE? By SARA J. HENNEBERGER A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN MASS COMMUNICATION UNIVERSITY OF FLORIDA 2009
2 2009 Sara J. Henneberger
3 To my parents, Charlotte and Jim Henneberger Thank you for your unending love and support
4 ACKNOWLEDGMENTS First and foremost, I thank my thesis ch airand adviser of th ree yearsDr. Cory Armstrong, for her guidance, patience, and hard work on my behalf. I am fort unate to have her as a mentor. I also wish to thank Dr. Kim Walsh-Childers for her helpful input on my thesis and her sage advice throughout my time in graduate scho ol. Many thanks also to Dr. Mary PeoplesSheps for her invaluable public he alth perspective and guidance as an adviser. I am grateful for the many contributions of each of my committee members. I also wish to thank Dr. Alba AmayaBurns for inspiring me to explore the field of public health. I thank my wonderful parents, who have offered me tremendous s upport during both this journey and all of my other endeavors. Lastly, I thank the University of Florida for allowing me the flexibility to pursue an interdisciplinary curriculum, and I thank all of my professors for sharing their expertise and providing me with a high quality education.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES................................................................................................................ .........8 ABSTRACT....................................................................................................................... ..............9 CHAPTER 1 INTRODUCTION................................................................................................................. .11 Human Papillomavirus........................................................................................................... 11 HPV Vaccine.................................................................................................................... ......12 Legal Status of HPV Vaccine.................................................................................................14 Purpose of Study............................................................................................................... ......16 Research Questions............................................................................................................. ....17 2 LITERATURE REVIEW.......................................................................................................18 Theory......................................................................................................................... ............18 Mass Medias Coverage of HPV Vaccine..............................................................................26 Knowledge About HPV..........................................................................................................29 Beliefs, Attitudes, and Behaviors Regarding HPV and Its Vaccine.......................................33 Health Information Sources....................................................................................................3 7 HPV Vaccine Acceptance.......................................................................................................40 3 METHODS...................................................................................................................... .......43 Quantitative, Online Survey...................................................................................................4 3 Descriptive Information........................................................................................................ ..47 Dependent Variable............................................................................................................. ...48 Independent Variables.......................................................................................................... ..48 4 RESULTS...................................................................................................................... .........53 RQ1: What Do College Women Ages 1826 Know About HPV and Its Vaccine?..............53 RQ2: What Are Their Beliefs and At titudes Regarding the HPV Vaccine?..........................53 RQ3: What Are Their Main Sources of In formation About HPV and the HPV Vaccine?....54 RQ4: What Has Most Influenced Their De cision-Making Regarding HPV Vaccination?....55 RQ5: How Have Their Knowledge, Beliefs, A ttitudes, and Other Factors Influenced Their Behavior Regarding HPV Vaccination?....................................................................56 5 DISCUSSION................................................................................................................... ......66
6 Limitations.................................................................................................................... ..........72 Future Areas of Study.......................................................................................................... ...75 Conclusion..................................................................................................................... .........76 APPENDIX A SURVEY....................................................................................................................... .........78 B CONSTRUCTION OF VARIABLES US ED IN REGRESSION ANALYSIS.....................91 LIST OF REFERENCES............................................................................................................. ..95 BIOGRAPHICAL SKETCH.......................................................................................................100
7 LIST OF TABLES Table page 3-1 Demographic information about survey respondents........................................................51 4-1 Real and perceived knowledge about HPV and the HPV vaccine.....................................58 4-2 Beliefs and attitudes ab out HPV and the HPV vaccine.....................................................58 4-3 Sources of information about health issues.......................................................................59 4-4 Sources of information about HPV....................................................................................60 4-5 Sources of information about HPV vaccine.......................................................................60 4-6 Mass media sources of information about HPV vaccine...................................................60 4-7 Observed locations of Gardasil advertisements.................................................................60 4-8 Interpersonal sources of information about HPV vaccine.................................................61 4-9 Frequency of media use for HPV information...................................................................62 4-10 Frequency of media use for health information.................................................................63 4-11 Primary influences on decision to get HPV vaccine..........................................................64 4-12 Primary influences on decision to not get HPV vaccine....................................................64 4-13 Primary influences on future decision regarding HPV vaccination...................................64 4-14 Media sources that have most influenced HPV vaccination decision...............................64 4-15 Hierarchical linear regression predicti ng individual intention to get HPV vaccine..........65
8 LIST OF FIGURES Figure page 1-1 Diagram demonstrating the Theory of Planned Behavior, including the influence of the mass media................................................................................................................. ..24 4-1 Mean frequency of talking with interpersonal sources about HPV vaccine......................61 4-2 Mean frequency of media use for HPV vaccine information............................................62 4-3 Mean frequency of media use fo r health information in general.......................................63
9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Mast er of Arts in Mass Communication KNOWLEDGE, BELIEFS, AND ATTITUDE S ABOUT THE HUMAN PAPILLOMAVIRUS VACCINE AMONG FEMALE CO LLEGE STUDENTS: DOES MASS MEDIA EXPOSURE INFLUENCE VACCINE ACCEPTANCE? By Sara J. Henneberger August 2009 Chair: Cory Armstrong Major: Mass Communication Human papillomavirus (HPV), which causes 99.7% of all cases of cervical cancer, is the most common sexually transmitted disease in the nation. Each year, cervical cancer strikes over 10,000 women in the United States and nearly half a million worldwide. The incidence of HPV infection peaks among women ages 2225. Gardasil, Mercks HPV vaccine, has proven nearly 100% effective against at least four strains of HPV responsible for most cases of cervical cancer and genital warts. In 2006, the Centers for Di sease Control and Prevention recommended the vaccine for women ages 1126. Although much attention has been paid to the issue of HPV vaccination among young girls, no studies about the know ledge, beliefs, and attitudes of the adult target population (women ages 1826) have been published since th e vaccine became available. In order to develop better health education messages and to eventually increase vaccination rates among women, it is important to understand what factor s influence their HPV vaccination decisions. In this study, research questions focused on colle ge womens level of knowledge about the HPV vaccine, their related beliefs and attitudes, th eir primary sources of information, and their decisions in favor of or against vaccination. A 55-question quantitative survey was used to
10 examine a variety of determinants that contribute to HPV vaccination decisions, with a particular focus on the influence of the mass media. A hierarchical linear regression showed th at three main factors accounted for 42.7% of the variance in individual intention to be vaccina ted against HPV. They were: 1) belief that the vaccine is safe and that information about the vaccine provided by advertisements and the news media is trustworthy; 2) perceived family support regarding vaccination; and 3) use of interpersonal sources of information about the va ccine. Stronger beliefs in vaccine safety and information trustworthiness were also correla ted with a positive overall impression of the HPV vaccine. The results suggest that college women may be significantly influenced by HPV information provided by advertisements, the news media, and interpersonal sourcesdespite the fact that respondents reported rela tively low use of these sources. The survey also revealed that the women were highly informed about the HPV vaccine. Their knowledge, combined with the information they gained from the news media and interpersonal sources, may have helped develop and/or reinforce their beliefs regarding HPV vaccine safety, whic h contributed directly to the decision to be vaccinated. This study fill ed a gap in knowledge about how college women have responded to the availability of an HP V vaccine and what factors most impact their vaccination decisions. These findings can help guide health educators and public health professionals as they work to promote HP V vaccination and eradic ate cervical cancer.
11 CHAPTER 1 INTRODUCTION Human Papillomavirus Human papillomavirus (HPV) is an ancient a nd widely spread virus that affects more than 20 million women and men in the United States (CDC, 2008a). Although it is overshadowed by higher profile sexually transmit ted diseases (STDs) like HIV/AIDS, herpes, and chlamydia, HPV is the most common STD in the nation. Spread primarily through skin-toskin and genital contact during sexual activity, HPV will affect more than 50% of adults at least once during their lifetim e (Koutsky, 1997; CDC, 2008a). Most cas es are asymptomatic and clear up without medical intervention (Gerberding, 2004) However, HPV causes 99.7% of all cases of cervical cancer, and while the disease is often caught in its early stag es in American women through Pap tests, worldwide it is the sec ond most common cause of cancer deaths among women (Walboomers, Jacobs, & Manos, et al., 1999; Ault, 2007). In 2007, cervical cancer struck about 11,000 women in the United States and nearly half a million worldwide. HPV also causes the majority of mouth cancers, including those of the tongue and tonsils (Gregorian, 2008). Although men are carriers of HPV and can devel op genital warts and HPV-related genital and anal cancers, HPV-related cancer among women is much more pr evalent (Irvine, 2008). Two strains of HPV16 and 18cause about 70% of all cases of cervical cancer (Ault, 2007). Women and men ages 2024, especially those at tending college, are most at risk for HPV infection (DUrso, Thompson-Robinson, & Chandl er, 2007). Adolescents and college students are at greater risk for STDs than many other segments of the population, primarily due to them having more instances of unprotected sex a nd more partners (CDC, 2009). Among women, the incidence of HPV infection peaks among thos e ages 2225 (Ludicke, Stalberg, Vassilakos, Major, & Campana, 2001).
12 In March 2008, the Centers for Disease Cont rol and Prevention (CDC) released data showing that one in four women ages 1419 in the U.S.3.2 million girlshad at least one STD (CDC, 2008b). Of those infected, the mo st common STD was HP V (18%), followed by chlamydia (4%). STDs disproportionately aff ect minority women: The CDC study found that nearly half of African American teen girls (48% ) had an STD, compared to 20% of white teens. The agency also reported th at although 82% of sexually active women ages 1524 receive contraceptive or STD/HIV testing services, on ly 39% receive both. An additional CDC report found that of young women seeking emergency contraceptivesindicating unprotected sex only 27% were screened for chlamydia or gonorrhea, and of those, 12% tested positive. This suggests a high rate of undiagnosed and unt reated STDs among young women. Compared to men, women suffer the most severe consequences from STDs, which, if left untreated, can lead to painful symptoms, infertility, and cancer. HPV Vaccine Gardasil, Mercks HPV vaccine, has proven ne arly 100% effective ag ainst at least four strains of HPV responsible for most cases of cervical cancer and geni tal warts (Ault, 2007). These results are based on four randomized trials involving mo re than 20,000 women ages 1529 from more than 24 countries in Europe, North Am erica, Latin America, and Asia. The ability of the vaccine to prevent the spread of the most dangerous strains of HPV makes it the most effective prevention method other than abst inence; condoms do not offer 100% protection against HPV (Irvine, 2008). It is unknown whether the vaccine offers lifelong protection against HPV. However, it offers 100% pr otection against HPV strains 16 and 18 for at least five years in women who are not already inf ected (Harper & Paavonen, 2008). Fu rther trials are needed to determine whether vaccine recipients w ill require booster shots later in life.
13 In June 2006, the U.S. Food and Drug Admi nistration (FDA) approved the vaccine, and the CDC subsequently recommended that it be gi ven routinely to all gi rls ages 1112, and that young women ages 1326 would also benefit from vaccination (CDC, 2008c). Vaccination is intended to take place before th e onset of sexual activity, and/or before a woman is exposed to the HPV strains that cause cervical cancer and genital warts (Gardasil. com, 2009a) This vaccine represents an important medi cal breakthrough, Dr. Anne Schuc hat, director of the CDCs National Center for Immunization and Respiratory Diseases, said at the time. These vaccine recommendations address a major health problem for women and represent a significant advance in womens health (CDC, 2006, 4). This view was largely echoed throughout the medical and public health communities, and in October 2008, th e Nobel Prize in medicine was awarded to the scientist who discovered HPV and its link to cervical cancerfindings that ultimately contributed to the development of an HPV vaccine (Altman, 2008). Gardasil is administered th rough three intramuscular injec tions over the course of six months. The vaccines are prophylactic and have no documented therapeutic activitymeaning they are designed only to stop initial transmission of HPV, not to treat existing cases of the virus (Wright et al., 2008, p. S42). Despite this, pr ograms promoting and/ or funding catch-up vaccination programs for women ages 1326 exist in several European nations and Australia, along with the U.S. The goal of these programs is to target women w ho have not yet been exposed to HPV strains 6, 11, 16, and 18even if th ey are sexually active (Wright et al., 2008). Harper and Paavonen estimate that if only 12-year-old girls are vaccinated, it will take 100 years to maximally reduce cervical cancer incide nce (Harper & Paavonen, 2008, p. A9). However, vaccinating women older than 12 years may acceler ate the reduction in cervical cancer rates (p. A9)
14 Clinical trials are currently being con ducted on women over the age of 26, and early results indicate that the vaccine is well-toler ated in women up to age 55 (Wright et al., 2008, p. S46). Although it is currently recomme nded only for younger women, vaccination could provide significant individual be nefit to many women older than 26 years of age, especially those with a relatively modest number of previ ous sexual contacts and those who will have new sexual exposures (Wright et al., 2008, p. S46). Legal Status of HPV Vaccine The HPV vaccine includes thre e injections and costs appr oximately $375a cost covered by most large insurance comp anies (CDC, 2008c). To addres s concerns about cost and awareness, at least 41 states and the District of Columbia have introduced bills to require, fund, or educate the public about the HPV vaccine, and 19 enacted the legislation, including Colorado, Indiana, Iowa, Louisiana, Maine, Maryland, Michigan, Minnesota, Nevada, New Mexico, New York, North Caroli na, North Dakota, Rhode Island, South Dakota, Texas, Utah, Virginia, and Washington (National C onference of State Legislatures, 2009, 8). Both New Hampshire and South Dakota provide the vaccin e free to girls younger than 18, and Washington has designated funds to vaccinate 94,000 girls during the next two years. In February 2007, Texas Governor Rick Perry signed an executive order mandating that all gi rls entering the sixth grade be vaccinated against HPV, but the Texa s Legislature passed a la w overriding the order, thereby leaving it up to parents to decide whether their daughters should receive the vaccine. The Virginia Legislature passed a vaccine mandate in 2007 but is currently considering a bill that would delay its implementation. In 2007, at leas t 24 states and the Di strict of Columbia introduced bills that would have mandated the HP V vaccine for school attendance. Thus far, only the District of Columbia has enacted such a law. HPV legislation has the potential to increase the availability of the vaccine and to make it more affordable to recipients through public funding.
15 Legislative action and the relate d media coverage also help in crease public awareness about the vaccine. In February 2007, Merck announced that it woul d stop lobbying state le gislatures to pass laws mandating the vaccine. This decision was made amid mounting public concern that the corporation was unduly influencing legislators to pass bills that would lead ultimately to a financial windfall for Merck (Pollock & Saul, 2007). The executive secretary for the FDAs Advisory Committee on Immunization Practices condoned Mercks decision to halt its lobbying program, stating that Anything that takes away fr om the process of getting [the] vaccine into people is deleterious to the whole pr ocess (Pollock & Saul, 2007, p. C1). Although the CDC currently recommends the vaccine only for women, regulatory agencies in Australia and the European Uni on have approved it for boys ages 915, as well. Merck is currently sponsoring a c linical trial of Gardasil in 4, 000 men; the results may impact the vaccines recommended use in the U.S. In the meantime, doctors in the U.S. are legally permitted to provide the vaccine to anyone they f eel is an appropriate candidate (Tuller, 2007). However, because Merck is forbidden from marketing Gardasil to men until it receives FDA approval, it is unlikely that many men in the U.S. will be informed about and receive the vaccine. Presently, Gardasil is the only FDA-appr oved HPV vaccine available in the U.S. GlaxoSmithKline has developed a similar vaccine, Cervarix, which has been approved for use in women and children in more than 67 countries, including all memb er countries of the European Union (Philadelphia Business Journal, 2008). In March 2007, GlaxoS mithKline filed an application with the FDA for the approval of Cervar ix; more than a year later, the drug company reported that it planned to submit new informati on about the vaccine and data from additional clinical studies to the FDA duri ng the first half of 2009. After that FDA approval is expected to
16 take at least six months. If and when Cervarix is approved, market competition may cause the cost of the HPV vaccine to go down, thereby making it more accessible to uninsured women. Purpose of Study HPV education and prevention is a timely topi c, especially given that the legislative status of the HPV vaccine remains in limbo across the nation. Much of the media coverage of the vaccine has focused on the opinions and actions of legislators and other government officials, and the beliefs and reactions of parentsspeakin g for or on behalf of their young daughters. The vaccine is, after all, recommended for girls ages 1112, and unless it is made mandatory, it is up to parents to decide if their daughters will receive it. However, the vaccine is also recommended for women up to age 26. Even if Gardasil is mandated for young girl s, todays young adult women ages 1826 still have the power to choose whether to be vaccinated, and they have a vested interest in the vaccine s availability and cost Many insurance plans currently cover this costly vaccine, but the number of vaccines given would likely skyrocket if more states mandate vaccination. Although the concerns and perspect ives of young adult women may echo those of parents and legislators, there ar e undoubtedly influences that uni quely impact their beliefs and decisions about the vaccine. The voices and expe riences of this age group have been largely overlooked by the media in their coverage of the HPV vaccine and its major stakeholders. Furthermore, much of the academic research conducted on this populations health beliefs regarding HPV was done prior to the availability of Gardasil. Public awareness about HPV has risen sharply during the last th ree years and this has likely influenced opinions regarding vaccination (Health Information National Trends Su rvey, 2008). In order to develop better health education messages and to eventually increa se HPV vaccination rates among college women and, ideally, all young adult womenit is important to understand what factors influence their decisions regarding HPV vaccination.
17 This study was grounded in both health behavi or theory and opinion formation theory. In order to determine what most significantly infl uences a young womans decision to get the HPV vaccine, one must first examine her underlying k nowledge, beliefs, and attitudes about Gardasil, and how those factors interact with outside influe nces. Although this study examined a variety of determinants that contribute to HPV vaccinati on decisions, it focused particularly on the influence of the mass media both on the formatio n of beliefs and attitudes and on behavior directly. The study revolved around the following key questions: What most influences college womens decisions regarding HP V vaccination? And, specificall y, what impact, if any, do the mass media have on the decisionmaking process? An anonymous survey was used to measure the knowledge, beliefs, attitudes, intentions, and behaviors of college women regarding the HPV vaccine. The results of this quantitative study offe r public health officials and health educators a better understanding of how information about HP V and its vaccine reaches college women and how it influences their vaccination decisions. With this new information, public health officials and health communicators are bett er equipped to tailor their me ssages and select appropriate channels through which to provide information about the HPV vaccine to a population of women that has much to gain from being vaccinate dand a limited window of time in which to do so. Research Questions The following research questions we re addressed in this study: RQ1: What do college women ages 1826 know about HPV and its vaccine? RQ2: What are their beliefs and attitudes regarding the HPV vaccine? RQ3: What are their main sources of in formation about HPV and the HPV vaccine? RQ4: What has most influenced their decision-making regarding HPV vaccination? RQ5: How have their knowledge, beliefs, att itudes, and other factors influenced their behavior regarding HPV vaccination?
18 CHAPTER 2 LITERATURE REVIEW Theory The Theory of Reasoned Action (TRA) and Theo ry of Planned Behavior (TPB) served as the foundational theories for this study. Both TRA and TPB are used to help predict human behavior. TRA, developed in 1975 by Martin Fishbe in and Icek Ajzen, posits that intentions are the strongest determinant of behavior, and that in tentions are influenced by social pressures and personal attitudes, which are in turn influenced by personal beliefs (Ajzen & Fishbein, 1980). In 1985, Ajzen expanded the theory and developed TPB by adding a third baseline factor: belief in ones control and ability to carry out a behavior (Ajzen, 1991). Th e concept of intention captures all motivating factors that lead to a particular behavior and reflects how hard people are willing to try. As a general rule, the st ronger the intention to engage in behavior, the more likely should be its performance (Ajzen, 1991, p. 181). Intention is driven by three conceptually independent determinants: attitude toward the behavior, su bjective norms, and perceived behavioral control (Ajzen, 1991, p. 181). Attitude describes a persons favorable or unfavorable evaluation or appraisal of the behavior in question (Ajze n, 1991, p. 188). Attitudes develop based upon ones behavioral beliefs, which are formed about something when we associate it with certain attributes, i.e., with other objects, characteristics, or events (p. 191). A persons belief s and ensuing attitudes link behavior to specific outcomes. Favorable beliefs and attitudes generally mean that one will believe that the outcome of a pa rticular behavior is also favor able. The level at which someone values a predicted outcome influences the stre ngth of the related be liefs and attitude. For example, a young woman who believes that she is at risk of getting HPV, that HPV causes cervical cancer, and that the HPV vaccine can help prevent it may develop an attitude such as
19 Getting the HPV vaccine is a good idea and therefore decide to get the vaccine, based on the strong potential for a desirable outcome (protection against cervical cancer). The second determinant of intention, subj ective norm, is grounded in normative beliefs, which are concerned with the lik elihood that important referent individuals or groups approve or disapprove of performing a given behavior (Ajzen, 1991, p. 195). The motivation to behave in a particular way is related to how strongly individuals care about how other important people in their life will react to the behavior. For example, a young woman who has the normative belief that her friends and family members will think she is promiscuous if she gets an STD vaccine may develop a subjective norm such as My loved ones do not want me to get the HPV vaccine , which may lead her to d ecide against vaccination. The third determinant of intention, perceive d behavioral control, is based on control beliefsan individuals belief about the pre sence or absence of requisite resources and opportunities needed to carry ou t the behavior (Ajzen, 189, p. 196). If people see few obstacles to achieving a behavior, they are more likely to pursue it. The belief that a certain behavior is achievable is based in part on past experience with the behavior, [but will] also be influenced by second-hand information the experiences of acquaintances and friends and by other factors that increase or reduce the perc eived difficulty of performing the behavior in question (Ajzen, 1991, p. 196). For example, a young woman may believe that she has low self-efficacy, leading to a perceived behavioral control such as I am unable to affo rd the HPV vaccine and a decision against vaccination. A host of ex ternal factors could contribute to low pe rceived behavioral control, including lack of money to pay for the HPV vaccine, lack of tran sportation to a health care clinic, or lack of a primary care provider.
20 Anderson and Lavalle (2008) tested the abil ity of TRA and TPB to predict athletes adherence to training and found that perceived be havioral control may be more influential by itself than intention. Although the athletes may have started out with good intentions, they were unable to convert these inte ntions into actual behavior due to other impediments that led to a lack of self-efficacy (Ande rson & Lavalle, 2008, p. 309). The authors concluded that TPB, rather than TRA, was most relevant to thei r study because of its inclusion of perceived behavioral control as a factor directly contributing to behavior. Pe rceived behavioral control becomes important in predicting behavior when volitional control is incomplete and barriers exist to prevent the individual from engaging in the behavior (Anderson & Lavalle, 2008, p. 310). Because college women may face various barri ers to vaccination (e.g., inability to pay for the vaccine or lack of time to go to the doctor) it is important to include perceived behavioral control in the analysis in order to develop a complete picture of how and why young women decide to be vaccinated. Both behavioral beliefs and control beliefs are influenced by many factors, including access to or lack of information. It is here that mass media sources fit into the Theory of Planned Behaviorthey help develop the key determinan ts of intention and ensuing behavior. Mass media health campaigns have been based around TP B, drawing on the idea that if information can be used to influence beliefs and attitudes, th en the resulting intentions and behaviors will be favorable. In their survey of women about the use of dietary supplemen ts, Conner, Kirk, Cade, and Barrett (2001) utilized TPB as the analytical framework and found that along with intention and its traditional trio of de terminants, the mass media (books and magazines) were also perceived by the participants as a power ful influence on a persons decision to use supplements (Conner et al., 2001, p. 621). User s of dietary supplements rated books and
21 magazines as more in favor of supplement use th an any of the other referents (Conner et al., p. 628). Interestingly, both users a nd non-users indicated that they wished to comply with the health information provided in books a nd magazines (Conner et al., p. 628). Maddock, Silbanuz, and Reger-Nash (2008) base d their study of the development of a mass media campaign to increase physical act ivity and nutrition among a multiethnic population on TPB, stating that similar campaigns have been successful in changing behavior (Maddock, Silbanuz, & Reger-Nash, 2008, p. 210). Their ca mpaign was designed to address the core beliefs in attitudes, perceived behavioral control, and subjecti ve norms that differed between those who were engaging in the behavior and those who were not (Maddock, Silbanuz, & Reger-Nash, p. 210). In the pilot st udy, control beliefs proved to be the most signific ant barrier to change. After being presented w ith health education campaign materials, study participants identified several perceived control beliefs, in cluding lack of time (to exercise) and lack of availability (of fruits and ve getables). Social normsprimar ily, the foods eaten by peers and family membersalso played a role in discou raging participation in the healthy lifestyle program (Maddock, Silbanuz, & Reger-Nash). The influence of the media can have bot h encouraging and discouraging effects on behavior. Lobb, Mazzocchi, and Traill (2007) used TPB to analyze the results of a survey about risk perception and trus t in food safety information in the United Kingdom. The authors found that in the event of a food contamination scare, trust in food safety information provided by media, alternative sources, and independent au thorities significantly reduces the likelihood to purchase (Lobb, Mazzocchi, & Traill, 2007, p. 393). Similarly, trust in information provided by media and independent sources increases risk percep tion, [while] trust in public authorities decreases it (p. 393). Risk percep tion negatively influences attitude s, which in turn influences
22 intent and behavior (in this case, the decision not to purchas e a possibly contaminated food item). Lobb et al. also found that in the event of a food scare, the traditio nal three determinants of intention and behavior are ov ershadowed by other influences, such as information provided by the news media or the government (pp. 393394). As a new vaccine for a largely unpublicized di sease, Gardasil started out with a relatively clean slate in the realm of public opinion. This ha s changed quickly during the past three years as doctors, legislators, parents, a nd interest groups of various polit ical, religious, and philosophical backgrounds weighed inoften on the editorial pages of newspapers and magazines, on Internet discussion boards and blogs, and on commentar y programs on television and radio. Although the development and use of Gardasil is a medical and scie ntific topic, it is also viewed by some as an ethical and values-based issue. For example, wh ile some define Gardasil as a cancer vaccine, others frame it as an STD vaccine. How a womans opinions about the vaccine are formed influences its personal relevance for her, and, for women in the vaccines target age group, it is a first step in their decisi on regarding vaccination. Taking on a longtime question in the field of public opinion formation, Nisbet (2005) explored whether increased information leads to greater public acceptance and supportin this case, for stem cell research. Expl aining the rationale for his survey, he writes, when it comes to public opinion about controversia l issues related to science a nd technology, many policy makers and scientists assume that increased public unde rstanding of the science will lead to increased public support (Nisbet, 2005, p. 90). However, indi viduals are often more likely to rely on their value predispositions and only the information most readily available to them from the mass media and other sources in order to formulate an opinion about science c ontroversy (p. 90). The hopes of scientists for an enlightened public are often unrealistic. Nisbet argues that:
23 the public is generally more miserly than fu lly informed. Instead of an omni-competent citizenknowledgeable and interested about all issuesindividuals are more likely to satisfice rather than optimize their use of information, relying on available heuristics as a means to process new information, form attitudes, and reach decisions (Nisbet, p. 94). These observations were demonstrated in Nisbet s analysis of national survey data. He did find, however, that in a year with heavy media c overage of stem cell rese arch (2001), the issue was more salient to respondents, who were more likely to express positive opinions regarding the research (p. 107). A year later, wh en media coverage declined, the i ssue lost some of its saliency and respondents were more likely to express ne gative opinions about stem cell research. Public opinion shifted again to a more favorable positi on in 2004, with the death of Ronald Reagan and the media coverage about the potential for stem cell research to lead to a treatment for Alzheimers disease. Since then, support has once again waned. Nesbit concludes that although an increase in awareness leads to an increas e in support for researc h, both religious and ideological value predispositions strongly mode rate the impact of awareness (p. 90). Ho, Brossard, and Scheufele (2008) also used the topic of embryoni c stem cell research to examine the effects of value predispositions, mass media use, and knowledge on public attitudes. After analyzin g data from a national survey, the au thors concluded that public opinion about the stem cell issue is largely shaped by value predispo sitions and heuristic cues from the news media, and demonstrates that scientific knowl edge plays a minor role in influencing attitude (Ho, Brossard, & Scheufele, 2008, p. 185). Based upon factors such as religiosity, ideology, and deference to scientific authority, respondents interpret very differently the same type of information, depending on which predispos itional lens they apply when making sense of that information (p. 185). Ho et al. found that positive news frames regarding stem cell research led to more positive attitudes about the topic by the public. These findings were consistent with past research that shows media use to be posit ively related to support for emerging science and
24 technology (p. 187). This suggests that the medi as news coverage of Gardasil and HPV may have a more positive than negative effect on young womans attitudes and decisions regarding vaccination. However, although college women may have access to similar information about the HPV vaccine from the mass media and health care professionals, their interpretation of this information is filtered through a va riety of personal values and prev iously held beliefs, leading to different attitudes and behaviors regarding vaccination. These factor s represent an important part of the current application of TPB; along with attitudes, subjective norms, and perceived behavioral control, college woman may be si gnificantly influenced by media cues and value predispositions. The following diagram, based on the work of Ajzen (1991), demonstrates the multiple factors that lead to intention and behavior. Along with the traditional trio of determinants (attitude, subjective norms, percei ved behavioral control) mass media have also been included as a direct infl uence on beliefs and behavior. Figure 1-1. Diagram demonstrati ng the Theory of Planned Behavi or, including the influence of the mass media Belief that a behavior can lead to certain outcomes Belief that other people think one should/should not engage in the behavior Attitude toward the behavior Subjective norm Intention Behavior Belief of personal control and perceived ability to engage in behavior Perceived behavioral control Mass media
25 In the current study of college womens s ources of information, knowledge, beliefs, attitudes, and behaviors regard ing HPV vaccination, the application and relevance of the Theory of Planned Behavior can be demonstrated through the following sample scenario. A college woman may be likely to receive the HPV vaccine if: 1) She believes that the HPV vaccine is safe effective, and can prevent her from becoming infected with HPV (based in part on in formation provided by the mass media), or 2) She believes that her peers, family me mbers, health care provider, etc.whatever groups or individuals are most important to herwa nt her to be vaccinated, or, at the least, will not have negative feelings toward her if she does, or 3) She believes that she has control over the decision to be vaccinated, and the ability to get the vaccine. Leading to: 4) A positive attitude toward the HPV vaccine, or 5) Perceived support for getting vaccinated, or 6) A sense of control and ability to get vaccinated. Leading to: 7) The intention to be vaccinated against HPV. Leading to: 8) Getting the HPV vaccine. A possible alternative to the above scenario centers on the influence of the mass media. As demonstrated by Conner et al. (2001), the mass media sometimes serves as an independent determinant of intention. For example, a wo man could find information presented by the mass media about the HPV vaccine so compelling that she is singularly motivated to be vaccinated.
26 Mass Medias Coverage of HPV Vaccine Immediately prior to and in the nearly thr ee years since Gardasils approval by the FDA, Americans have been presented with informa tion and opinions about HPV vaccination from a variety of media sources. In November 2006, Merc k launched a national print, television, and online advertising campaign for Gardasil. Th e One Less campaign urges young women to become one less person who will battle cer vical cancer (Medical News Today, 2006). The widely run television commercials feature an et hnically diverse array of mothers and daughters engaging in a variety of activities. They skateboa rd, bake cookies, play checkers, ride horses, and read magazines, all while informing viewer s about the benefits and risks of Gardasil (Gardasil.com, 2009b). The commercials end with the text, Choose to get vaccinated. An article in The New York Times describes the daughters as the c oolest girl in the room, whatever room shes in (Dederer, 2007, p. 2.34). In many of the commercials, the mothers list the possible side effects of vaccinationincluding so reness at the injection site, headache, fever, nausea, dizziness, vomiting, and fainting (Gar dasil.com, 2009b). Having mothers voice the downside of Gardasil reinforces th e message that if you get this vaccination, youre a rebellious, independent thinker, writes Dederer (p. 2.34). Forget Mom. Im gettin vaccinated. The Gardasil.com Web site, published by Merck, includes clips of the commercials, a printable HPV fact sheet, a slideshow, and tip s on planning an event to get the word out about HPV and cervical cancer (Gardasil.com, 2009c, Make an Impact/Tools to Share section). The news media provided heavy coverage of the vaccines debut in June 2006, and reporting has since come in waves as debates have arisen over the vaccines safety, expense, and legal status across states. Along with news stories, numerous opi nion pieces about the vaccine have appeared in newspapers and magazines in print and online. Due to the relative newness of the topic, no published studies about the news medias coverage of Gardasil exist. However,
27 casual observation reveals that much of the c ontent has focused on defining and explaining HPV and its risks, explaining how the vaccine work s to prevent cancer, discussing the risks and benefits of HPV vaccination, and outlining the vari ous public debates that have arisen over HPV vaccination. Major medical organizations have spoken out through the mass media in favor of universal vaccination against HPV. However, so me have raised doubts about the thoroughness of the clinical testing of Gardasil. When the New England Journal of Medicine published two articles critical of the vaccine in its August 21, 2008, ed ition, these counter pe rspectives quickly made their way into the mainstream press via The New York Times (Rosenthal, 2008). Coverage of the vaccine has been repeatedly reinvigorate d during the last three years through the reporting of related news items, such as concerns over vacci ne safety in general, debates over abstinenceonly education, and new data fr om the CDC about STD rates. To better understand the dominant public pe rspectives on the HPV vaccine, as presented in the mainstream media, the author conducted a quali tative analysis of 31 letters to the editor, 22 op-ed or commentary pieces, and 21 newspaper board editorials published in 20062008 in mainstream American newspapers, including severa l student newspapers at secular universities, and two national news magazines (Henneberger, 2008). Among the opinion pieces written against HP V vaccination, several authors stated that they were worried about side effects and long-term health im plications for young girls. Many also said that the vaccine is prohibitively expensive and that resources should go toward promoting safe sex and/or abstinence. The best way to prevent HPV is to be sexually responsible by being abstinent outside of ma rriage and faithful within marriage and getting regular Pap tests, a woman wrote to the Washington Times Several expressed the belief that HPV is not truly a communicable disease, since it is sexually transmitted and is generally a
28 result of a personal choice. This, some author s argued, means that the HPV vaccine should not be mandated nor funded by the government. With the HPV vaccine, we are attempting to prevent a behavioral problem w ithout addressing the problem. Ce rvical cancer is largely a problem of sexually active women. Infection is a byproduct of that behavior, a man wrote to U.S. News and World Report Others wrote that the vaccine will encourage promiscuity. I think the hypothesis that people are more promiscuous af ter being inoculated w ith a HPV vaccine is completely reasonable, a man wrote to the Daily Collegian at Penn State University. Among the letters in favor of HPV vaccina tion, many authors cited statistics about the prevalence of HPV and cervical cancerand about the success of the vaccine based on clinical trials. Many also expressed con cern about paying for the vaccine and called for Gardasil to be made mandatory as a way to force insurance comp anies and state health care plans to pay for it: The HPV vaccine should become an affordable routine part of health carebecause the decisions we make today about preventing cervical cancer will directly aff ect the health of our daughters and our daughters daugh ters, a woman wrote to the Journal Gazette of Fort Wayne, Indiana. Another called for mandatory school-bas ed immunization as the only effective way to achieve widespread immunization and close racial, ethnic and soci oeconomic gaps in immunization rates in a letter to The New York Times One author described her own battle with cervical cancer in a letter to the San Francisco Chronicle concluding, You can bet my daughter will be receiving the new HPV vaccine! Some aut hors also suggested that the entire debate over HPV vaccination is based upon sexist assumpti ons: My guess is that if they found an immunizing agent for 15-year-old boys to preven t future prostate cancer, they would pass the law with flying colors and administer it without argument, a man wrote to the San Diego Union-Tribune We find a radical breakthrough in women s health controversial simply because
29 its working mechanism suggests that women have sex, a woman wrote in a column for the Daily Princetonian Newspaper board editorials were more like ly to endorse the vaccine than editorials penned by members of the public. This is likely a reflection of the p redispositional lens discussed by Ho et al. (2008). Despite largely positive news coverage about the vaccine, individuals continue to filter what for some is a controversia l issue through th eir own set of values and beliefs, leading them to different conclusions regarding the necessity, safety, accessibility, and legality of HPV vaccination. La rger, more thorough content analyses are needed to better analy ze the mainstream news medias co verage about Gardasil; however, general observations reveal that much of th e news coverage acknowledges or expands upon the dominant perspectives offered in letters to th e editor, columns, and op-eds on this topic. Knowledge About HPV Studies consistently show that adolescents and adults lack basic knowledge about HPV and other STDs. An anonymous survey of 322 firs t-year college students revealed that although more than 95% of both women and men indicated they had heard of gen ital warts, about twothirds of the women and three-quarters of the men did not know their cause, which is HPV (Baer, Allen, & Braun, 2000). Furthermore, only 35.5% of women and 29.1% of men said they had heard of HPV infection of the cervix, and 22% of women and 23.3% of men said they had heard of HPV infection of the peni s (Baer, Allen, & Braun, 2000, p. 70). Most worrisome, 45.6% of women and 82.6% of men stated that they did not know how HPV is transmitted (p. 72). The survey results also indicated that HPV lack s saliency among this age group. Only 4.6% of women and 2% of men listed HPV as a common STD, despite its status as the worlds most prevalent STD (p. 72). The survey found that 87% of participants had learned about STDs in health education classes in middl e or high school, and that 43.7% of women identified magazines
30 as an important source of information about STDs, compared to 23% of men (73). Twice as many men as women identified television as an important source of information about STDs (p.p. 7475). An anonymous survey of 351 black students rev ealed that a majority lacked awareness of the very existence of HPV (DUrso, Thompson-R obinson, & Chandler, 2007). Sixty-four percent of respondents stated that they had never heard of HPV prior to the survey (DUrso, ThompsonRobinson, & Chandler, 2007, p. 161). Among those who ha d heard of it, only 52% said that they knew what it was. Even among students who re ported that they knew about HPV, many incorrectly answered basic questions about HP V symptoms and transmission (e.g., over one-third stated that HPV causes herpes). Among students who reported that they knew about HPV, 62% received their information from a health care provider; 59% from a h ealth education program; 39% from a newspaper or magazine; 29% from th e Internet; and 20% from a friend or family member (p. 161). The remainder cited radio/te levision, the CDC STD hotline, the American Social Health Association, or other, unidentified sources. A qualitative study of Latina college student s beliefs about HPV revealed that approximately 11 out of 16 focus group partic ipants did not know anything about HPV (Schiffner & Buki, 2006, p. 691). Among the sexually active participants, 73% said they were somewhat to not at all concerne d about contracting the infecti on (p. 691). This ambivalence was likely rooted in their overall lack of awareness about the poten tially deadly consequences of HPV: 80% were unaware that cervical cancer can be fatal, and 40% did not know that cervical cancer can be asymptomatic (p. 692). Studies have shown that both adolescent and adult women prefer to receive information about STDs and/or HPV from their health car e providers. A qualitative study of 18-year-old
31 college womens communication about STDs found that 13 of 15 participants preferred interpersonal information sources (Rouner & Li ndsey, 2006, p. 34). Seven out of 15 said they preferred information to come from a doctor or other health care provider because those individuals would know the most or would be the most trustwor thy (p. 34). Four of 15 said they would talk with their friends about STDs, a nd four said they would speak with their mother. The women were divided in their use of the In ternet for information about STDs. Seven of 15 said they would not use it due to either not having access, not trusting the information, or not having been successful at past atte mpts to access health information online. The other half of the group had a more favorable view of the Internet as an informati on source. Several even selected it as their first choice for STD information. Th e top reasons included privacy, confidentiality, and easy access. Thirteen of 15 said they did not trust womens magazi nes as a source of information about STDs. Despite their stated c onfidence in their ability to acquire knowledge, the women were found to have a poor understand ing of STDs. About one-third of respondents said they could not identify any symptom of any STD (p. 33). The researchers described the participants as self-confident a nd resolute in their ability to make sound decisions because of their perceived knowledge about STDs, despite their demonstrated lack of knowledge (p. 32). The authors suggest this could be characteristic of college women, who may actually be less informed and less aware of their ignorance than noncollege women (p. 34). Information access did not necessarily lead to co rrect knowledge and practice. Rouner and Lindsey summed up the participants as empowered but ill informed about STDs (p. 34). Another study examined the information pr eferences of low-income women who had had an abnormal Pap test within the previous five years (McCree, Sharpe, Brandt, & Robertson, 2006, p. 166). Less than half the stud y participants reported that their health care provider had
32 told them that they had HPV, demonstrating a missed education opportunity with potentially dangerous health consequences. The womens preferences for in formation regarding HPV were based on convenience, privacy, trust, format, app eal, and comprehension (p. 169). Most of the women stated that conversation with a trusted clinician along with the opportunity to ask questions was preferable to the use of educatio nal materials (p. 169). The women also suggested that other women with HPV and/or abnormal Pa p test results were valuable sources of information, in that they offered both suppor t and easily comprehendible information (p. 169). Among other sources of information about HPV, the women said they preferred brochures and pamphlets, particularly those pr ovided by their health care provide rs. The main reason given for this preference was that the brochures could be taken home and read in private (p. 169). The women had negative impressions of tele vision and radio as reliable sources of information about HPV. Participants suggested that they could not trust the information provided via television and that the messages were often conf using and contained conflicting information (p. 168). The women also stated that they lacked trust in the validity of health information provided on the radi o, and that information from th e Internet was too confusing and not very reliableand that many of th em lacked access (pp. 168169). Magazines and books also received negative ratings, with some part icipants stating that the materials were too complex and hard to comprehend, particularly for people with low levels of literacy. Although this study focused on low-income women, the overarching themes regarding information preferences may be similar for other groups. No matter what their income level, women likely prefer that information about HPVand STDs, a nd health issues in generalbe trustworthy, confidential, easy to understand, and convenient. This study was also consistent with other
33 studies in reporting that women prefer to receive health information directly from their health care providers (Rouner and Lindsey, 2006; HINTS, 2008). Beliefs, Attitudes, and Behavior s Regarding HPV and Its Vaccine Womens lack of awareness about the existe nce and effects of HPV negatively impacts beliefs and attitudes about the disease and its va ccine. Lack of knowledge often translates into lack of concern about transmission and infec tion, despite evidence that young adults are generally concerned about their risk of contract ing an STD (Baer, Allen, & Braun, 2000). In their survey of first-year college students, B aer, Allen, and Braun found that although 80% of respondents stated that they considered themselves to be at low risk for contracting an STD, 70.6% of women and 73.5% of men said they were somewhat or very concerned about STDs (Baer, Allen, & Braun, 2000, p. 72). More than 95 % of those surveyed said they were most concerned about contracting HIV/AIDS. From a list of eight STDs (including HIV/AIDS, herpes, Hepatitis B, syphilis, genital warts, gono rrhea, chlamydia, and HPV), 4% of respondents said that they were most concerned about HPV (p. 73). Based on these results, the authors suggest that although the AIDS epidemic has incr eased awareness of and preventive measures against HIV/AIDS, this trend has not exte nded to other STDs, including HPV (p. 75). Furthermore, because HPV can be spread through skin-to-skin contact, the classic safe sex campaigns popularized during the AIDS epidemic are of only limited value for prevention of infection with HPVs (p. 76). This theme was echoed by DUrso, Thompson-Robinson, and Chandler (2007) who found that 94% of survey ed students believed that condoms prevent the spread of HPV. Belief in condoms efficacy in pr eventing the spread of HPV and other STDs did not necessarily impact behavior: Nearly one-fourth of surveyed students reported that they took no precautions against contracting STDs (D Urso, Thompson-Robinson, & Chandler, 2007, p. 161).
34 This trend was also reported by Schiffne r and Buki (2006) in their study of Latina students. Although all of the sexually active participants said they believed it is important to use condoms, less than half did so consistently. The discrepancies between th eir reported attitudes and actual behaviors suggest that they have the potential to enga ge in risky behaviors, write Schiffner and Buki (2006, p. 694). This fact means that they are unable to protect themselves fully from acquiring HPV because they are not ta king advantage of a resource that can provide some protection (2006, p. 694). Similarly, although 88% of th e women reported knowing how often they should have a Pap test, only half reported ever having ha d one (p. 692). The women said they would feel guilty, regret ful, angry, and stigmatized if they were to be diagnosed with an STD; however, their concerns about being screened for HPV through a Pap test seemed to outweigh those factors. Primarily, they feared that if they went to a doc tor for a Pap test they would be perceived negatively by their family and friends, and their privacy and sexual autonomy would be compromised. In 2003, the CDC commissioned a series of 36 focus groups nationwide to assess the knowledge, attitudes, beliefs, a nd communications preferences of the general public about HPV (Friedman & Shepeard, 2007). More than 300 peopl e participated in the focus groups, which were stratified by gender, race/e thnicity, and geographic location. When participants were asked to describe what they thought of when they heard the terms sexually transmitted disease or STD the most common responses included promiscuity, infidelity, shame, embarrassment, guilt, and divorce (Friedman & Shepeard, p. 475). When asked to list common STDs, HPV was rarely brought up, and when it was mentioned, onl y one or two people in the group had heard of the virus; the others reacted in surprise, noting that they ha d never heard of it (p. 475). Awareness was slightly higher among women than men. Those women reported having learned
35 about HPV from doctors, friends with HPV, a nd magazine articles. Overall knowledge about HPV was very low: Among all focus group partic ipants, only three knew that HPV can cause cervical cancer. When moderators informed the groups of this link, female participants in particular responded with fear and shock, and asked numerous follow-up questions. Some participants also questio ned why they had never been told about HPV. Some African American participants suggested a government conspi racy, referencing both the Tuskegee syphilis experiment and what some people view as the governments attempt to withhold information about HIV/AIDS during the early stages of the epidemic. When asked how they would feel about a hypot hetical vaccine against HPV, participants expressed ambivalence. First, they listed concer ns about the safety, side effects, and personal necessity of such a vaccine. Ma ny of the participants did not vi ew themselves as candidates for an HPV vaccine. Their lack of perceived susceptib ility to HPV emerged as a barrier to vaccine acceptability (p. 477). Married partic ipants said they were not at risk for HPV. Many parents stated that their children were not at risk, and/or that vaccin ation may encourage promiscuity. Participants also worried that they would be view ed as promiscuous if they received the vaccine. Embarrassment was cited as a possibl e barrier to vaccination. Some pa rticipants also feared that the vaccine would be prohibitive ly expensive. All groups stat ed that they wanted more information about HPV and its hypothetical vaccine. Friedman and Shepeard write that general lack of knowledge about HPV served as a barrier to part icipant acceptance of a hypothetical vaccine, as they did no t know the prevalence or potenti al consequences of HPV, nor did they understand their own level of HPV risk and susceptibility (p. 480). Although most participants said that the stigma of STDs migh t prevent them from seeking out more information in th e future, they said that if they wanted information about HPV,
36 they would turn primarily to th e Internet and their h ealth care providers. They also suggested clinics, schools, magazines, local television ne ws, and national television advertisements as appropriate vehicles and settings for delivering this information (p. 479). Citing concerns about privacy and stigma, the majority stated that th ey would not want to r eceive information about STDs in the mail. Participants in all groups said that they would not tr ust information developed by pharmaceutical companies (p. 480). The most trusted sources of information about HPV included the American Red Cross, Planne d Parenthood, community-based organizations, doctors offices, health departments, clinics, he alth insurance companies, and the CDC, although some African American particip ants said they would not trus t information from government agencies (pp. 479480). A later survey of 400 mid-adult women (> 25 years old) found higher levels of acceptance of HPV vaccination (Ferris, Waller, Owen, & Smith, 2008). Once again, knowledge about HPV directly influenced acceptance. Women who kn ew that HPV can cause cervical cancer were more likely to want the HPV vaccine than those who did not. They were also more likely to believe that it is important for their children or partner to be vaccinated. Many considered vaccination of their sexual partner(s) to be very important (Ferris et al., 2008, p. 36). Also, mothers who wanted their children to be vaccina ted were more likely to want the vaccine themselves. Women who considered it too late to get the vaccination, due to the likelihood that they had already been exposed to HPV, were less likely to want the vaccine, as were monogamous mid-adult women. Overall, these re sults suggest the need for increased HPV education for women not currently in the targ et age group for vaccination. Not only are these women key in deciding whether th eir children will be vaccinated, but catch-up vaccines for older women may be recommended by the CDC in the future.
37 An anonymous survey of 340 college students found a high level of intent to receive an HPV vaccineprior to the availability of Ga rdasil (Jones & Cook, 2008). Eighty-eight percent of women and 77% of men expressed an inte rest in being vaccinated (Jones & Cook, 2008, p. 26). Several factors positively influenced vacc ine acceptance, including ever having an STD, having a close friend or relative have HPV, ever having had sex, and having had more than five sex partners, along with availability of a free vaccine, a doctors recommendation, and recommendations from a spouse, parent, or frien d. (p. 25). People who perceived themselves as being at higher risk for contracting HPV were mo re likely to express an interest in vaccination. Conversely, sexually inexperienced participants were less likely to want the vaccinea problem, since the vaccine is most effective when given be fore the onset of sexual activity. Being told that they would have to pay $50 for the vaccine (muc h lower than the actual cost) also decreased acceptability. Acceptance was not associated with age, race, HPV status, perceived severity of HPV, or perceived knowledge of HPV (71% of wo men and 79% of men described themselves as not at all knowledgeable about HPV) (pp. 2526). However, women ages 1819 were more likely to accept the vaccine than women ages 2032. Jones and Cook suggest that health educators leverage college student s overall high levels of inten tion and ensure that they follow through with vaccination, since administration of th e vaccine is key to its success (p. 28). Health Information Sources The Health Information National Trends Su rvey (HINTS), developed and maintained by the National Cancer Institute, reveals similar trends regarding prefe rred sources for health information. Data collected in 2007 in a nationally representative telephone survey of the general population found that people prefer to receive health or medical information from health care workers. Asked how much they would trust inform ation about health or medical topics from a doctor or other health care professional, 68% said a lot, 25% said some, and 6% said a little or
38 not at all (HINTS, 2008). In comparison, when asked how much they trusted health care information provided by family or friends, only 15% of respondent s said a lot, 47% said some, and 37% said a little or not at all. In data collected in 2005 and 2007, the surv ey assessed respondents trust in medical information provided by various me dia sources. Newspapers, magazi nes, and the Internet were the most trusted sources and received similar ra tings, with, on average, 19 % trusting them a lot, 50% trusting them some, 19% trusting them a lit tle, and 9% not trusting them at all (HINTS, 2008). Survey data from 2005 found th at of respondents who reported that they use the Internet, 61.5% of them had looked for health or medical information for themselves online during the past 12 months. Radio and television were rate d significantly lower as trustworthy sources of health information, with only 5% of respondents trusting them a lot, 33% trusting them some, 39% trusting them a little, and 22% not trusting them at all. Respondents also reported that they paid at tention to information on health or medical topics reported in the media. Twenty-five percent said they paid a lot of attention and 31% paid some attention to health stories reported by ne wspapers and magazines. Television proved more populardespite its ranking as a less trustwor thy source of health informationwith 34% paying a lot of attention and 38% paying some attention to broadcasts about medical topics. Although the Internet was shown to be a relatively trusted source among respondents, only 13% said they paid a lot of attention and 16% paid some attention to online medical information. Because this particular data was collected in 2003, a higher percentage of respondents may now report going online for medical information, as Internet access has increased nationwide. Although respondents reported that their first choice for health or medical information is a health care professional, when it came to HPV and the HPV vaccine, most had received
39 information from other sources. Twenty-six percent reported hearing about HPV from a newspaper or magazine, 24% from a television advertisement, and 11.5% from television news (HINTS, 2008). Among other media sources, only 0.6% learned about HPV from the Internet, 1.2% from the radio, and 0.3% from pamphlets, posters, etc. Among non-media sources, 18% had learned about HPV from a medica l professional and 9% had lear ned about it from family or friends. This data suggests that although responden ts would prefer to hear about a topic like HPV from their health care provider, they are instead l earning about it from other, less trusted sources. When female respondents were asked if a health ca re professional had ever talked to them about the HPV vaccine, only 12% said yes. Data comparisons between 2005 and 2007 show a significant increase in the populations knowledge of HPV and the HPV vaccine. In 2005, only 38% of respondents had heard of HPV, compared to 65% in 2007 (HINTS, 2008). Basi c knowledge about HPV also increased during this time period. In 2005, 47% of respondent s knew that HPV can cause cervical cancer, compared to 78% in 2007. Also in 2005, 64% knew that HPV can be spread through sexual contact, compared to 67% in 2007. In 2007, 71% of respondents reported that they had heard of the HPV vaccine. Within two years (coincidi ng with the FDA approval of Gardasil), the population saw a dramatic increase in its knowle dge about HPV and the HPV vaccine; however, it appears that much of that knowledge was gain ed from non-medical, media sources. Because respondents expressed less trust in the mass media as a s ource of medical information, this raises questions about how people process and res pond to their new knowledge about HPV and its vaccine. There is a clear disconnect between information sources and possible avenues for personal health behaviors (getting vaccinated, ta king precautions to avoid HPV infection, etc.) when so few respondents report having ever hear d their health care provider mention HPV or the
40 vaccine. When 71% of respondents say that they are familiar with the HPV vaccine, yet 88% of women report that their health car e provider has never discussed it with them, this represents a missed opportunity for further education and ensuing action. Although the vaccine is not currently designated for most of the female adult population, many women are still impacted by the vaccines availability, pa rticularly as mothers. HPV Vaccine Acceptance Because it has been available in the United St ates for less than two years, overall trends in HPV vaccination acceptance are still unknown. In October 2008, the CDC reported that 25.1% of female teenagers had started the three-sh ot vaccination series in 2007 (CDC, 2008d). By comparison, 87.6% of teens received the three-do se Hepatitis B vaccination series during the same period. Total numbers of HPV vaccinations have not yet been reported, although a metaanalysis by Herzog, Huh, Downs, Smith, and Monk (2008) found considerable interest in HPV vaccination among adults and young adults, including college students (p. S5). Of the 5 million doses of Gadasil given out by March 2007, nearly th ree-quarters of the recipients were between the ages of 9 and 17 (Herzog et al., 2008, p. S8). Overall, HPV acceptability has been high despite generally low levels of knowledge of HPV (p. S5). One potential problem identified with Gardasil uptake is patient compliance with the three-dose vaccination schedule (Herzog et al., 2008). Because adolescents do not frequently visit their health care providers, it can be difficu lt to ensure that patients receive the required three doses of the vaccine over th e course of six months. Accordi ng to Herzog et al., first-dose vaccine compliance does not pose as great a probl em as continuation through second and third doses of the vaccine (p. S8). The burden falls on health care providersand, in some cases, parentsto enforce compliance w ith the protocol. Another obstac le to uptake is lack of awareness about the HPV vaccine. Herzog et al. write that less than 25% of patients, or mothers
41 of patients, reported receiving information from their physicians about HPV and/or HPV vaccination (p. S5). Instead, they got their in formation from nonscientific media sources, including television (p. S5). A lthough this information gap does not appear to have negatively impacted uptake thus far, it is a problem that must be addressed by health communicators and health care providers in the future to ensure widespread acceptance. Health care providers know that vaccine acceptance am ong the public can be a slow, painful process. After the first Hepatitis B vacci ne was approved for use in 1981, it took a decade for the vaccine to become widely accepted. In th e interim, the U.S. experienced a 37% increase in the incidence of Hepatitis B, with some 300,000 new infections each year (Morbidity and Mortality Weekly Report, 1991). The vaccine is recommended by the CDC for all infants and children, and since 1991, the United States ha s seen a 90% reduction in infections among children and adolescents and a 67% reduction overall (Altman, 2005). Based on the publics initial reluctance toward the He patitis B vaccine, health care pr oviders can expect a similarly slow acceptance of the HPV vaccine. One of the goals of this study is to help speed that process and to contribute to improved awareness and acceptance of the HPV vaccine among college women during the years when they are most vul nerable to infection (Ludicke et al., 2001). HPV vaccine acceptance may also be impacted by increasing backlash against childhood immunizations. In 1998, re search published in The Lancet suggested a possible link between the measles, mumps, and rubella (MMR) vaccine an d autism (10 of the 13 authors later retracted their hypothesis) (Park, 2008, p. 38). Since then, public debate ha s mounted about the overall safety of childhood vaccines, with some parents refusing to allow their infants or children to receive any vaccines. Today, 23% of all children enrolled in public school are unvaccinated due to philosophical or relig ious beliefs, and the number is beli eved to be growing (p. 38). Various
42 scientific studies and the National Institutes of H ealth have reported repeatedly that there is no evidence of a link between vacci nes and autism. Thimerosal, a preservative used in vaccines until 2001, has also been shown to have no link to the disease (p. 40). Although much of the debate over vaccine safety focuses on the pot ential risks to very young children, it could negatively impact adults views on vaccines and se rve as a discouragement from receiving new vaccines. In order to successf ully inoculate a population of young women against HPV, health care providers and educators must combat nega tive messages regarding vaccines and address patients concerns about safety and long-term side effects. The current study fills a gap in knowledge a bout how college women decide to get the HPV vaccine and how information provided by the ne ws media influences vaccine acceptance. It also helps expose possible gaps in perceived ve rsus real knowledge about HPV among college women and how that impacts their behaviors. Prev iously discussed studie s indicate that women are lacking in accurate information about HPV a nd the HPV vaccine; data has also shown that public knowledge about HPV has increased during the past three years. This is a pivotal time in the education of the public about the HPV vaccine, and this study offe rs an initial examination of how the medias coverage of the HPV vaccine ha s influenced the knowledge, beliefs, attitudes, and decisions of college women regarding vaccination. The study results may be helpful to those developing and disseminating more effectiv e messages about the HPV vaccine, thereby improving vaccine awareness and acceptance and ev entually reducing rates of HPV and cervical cancer.
43 CHAPTER 3 METHODS Quantitative, Online Survey An online survey was developed to assess the knowledge, belief s, attitudes, and behaviors of University of Florida female students rega rding HPV vaccination. Although this was a sample of convenience, a university campus is an approp riate and highly relevant location to gather information about young women ages 1826, given th at this age group comprises nearly 87% of college students in the United States (Student Affairs Administrators in Higher Education, 2008) and the women are within the HPV vaccines target population. Web-based surveys have become increasingly common during the past decade as more of the population has gained access to the Internet In 2008, the Pew Internet & American Life Project reported that 73% of Americans are Inte rnet users, and 55% of adult Americans have a high-speed Internet connection at homean in crease of 8% since early 2007 (Horrigan, 2008). All University of Florida students have free acce ss to computers and the Internet on campus, and most own computers and have broadband Intern et access at home. The universitys computer requirement policy states: Access to and on-going use of a comput er is required for all students to complete their degree programs successfully. While the university offers limited access to computers through its computer la bs, most students will be exp ected to purchase or lease a computer that is capable of dial-up or network connection to the Internet (and) graphical access to the World Wide Web .... (U niversity of Florida, 2008a). Co mputer and Internet access was expected to impact neither the number of survey respondents nor their answers. To confirm this, a survey question was included asking what co mputer the respondent was using to take the survey (e.g., private versus public).
44 In a study examining whether print and Webbased surveys yield the same results, Huang found no significant differences in participan ts responses (Huang, 2006, p. 346). Huang cautions that differences in respondents to print versus Web-based surveys may skew results. Because the typical Web survey user has private access to a computer, shows great er responsibility, and is better paid, they may have different knowledg e, beliefs, attitudes, and behaviors than the general population (p. 346). Likewise, because univ ersity students tend to have higher levels of income and education and greater access to hea lth care and health insurance than the general population, they may be more informed about health issues, includi ng HPV and its vaccine (Student Affairs Administrators in Higher Educ ation, 2008). These potential biases are mitigated by the fact that the vaccine is recommended onl y for women up to the age of 26not the general population. The survey was administered to memb ers of the vaccines adult target population. Due to the sensitive nature of some of th e questions, anonymity was crucial to the success of the survey and also helped dictate the quantitative versus qualit ative methodology. Ong and Weiss define sensitive questions as those for which privacy manipulatio n yields a difference in response proportions (Ong & Weiss, 2000, p. 1703). When studying stigmatized behaviors, anonymous surveys (in which the researcher does not know the identity of the respondent) have proven more accurate than confidential surveys (in which the researcher knows the identity of the respondent but has promised c onfidentiality) (Ong & Weiss, 2000). When potentially sensitive matters are explor ed, the perceived privacy inherent in the data-collection mode may be the most importa nt property, write O ng and Weiss (p. 1693). When presented with sensitive survey questions, respondents try to minimize their discomfort by presenting favorableand sometimes inaccurateinformation about themselves in order to preserve their positive self-image (p. 1693). A ccording to Ong and Weiss, anonymity reduces
45 concern with self-presentation because ones actions are no longer monitored by others (p. 1694). In their study of cheating behaviors in students ages 1825, Ong and Weiss found that anonymous surveys induced many more revelati ons than confidential surveysspecifically, anonymity yielded 34% more instances of cheating (pp. 17011702). Based upon the findings in the preceding literature review, it was expected that some of the survey respondents in the present study would have negative feelings a bout HPV and its vaccine. Anonymity increased the likelihood that they would be willing, truthful participants despite these concerns. The 55-question survey asse ssed participants actual a nd perceived knowledge, beliefs and attitudes about HPV and the HPV vaccine, v accination status and desire, and influences on decisions regarding vaccination. ( See Appendix A. ) It included three true/f alse questions to test actual knowledge about HPV and its vaccinea method employed by Jones and Cook (2008) in their study of the intent of college students to receive an HPV vaccine. In that study, participants who answered at least two of th e three knowledge assessment questi ons correctly were classified as knowledgeable about HPV (Jones & Cook, 2008, p. 25). They subsequently found that participants with the highest actual knowledge about HPV expressed a significantly greater intent to receive the vaccine (p. 23). In the curre nt survey, the answers to all three true/false questions have been widely reported in th e news media and in Gardasil advertisements. Questions were also included assessing percei ved knowledge about HPV and self-confidence in protecting oneself against infection. Several ques tions also assessed media consumption patterns for HPV-specific and general health information. The majority of the survey was closed-ended, and included Likert-scale, multiple-choice, categorical, and numerical questi ons. Benefits of this design in clude greater ease of scoring, analysis, and interpretation (Fi nk, 2008, p. 17). It also allowed for an alysis of factors predicting
46 individual intention to be vaccinated. The surv ey included one qualitati ve, open-ended question to give participants the opportunity to share their feelings about vaccines in general. Prior to launching the survey, the inves tigator tested it on 10 women in the target population in order to identify a nd remedy confusing, misleading, or irrelevant questions. Pilot test participants were asked to submit comments critiquing the questions. Based upon this input, combined with the preliminary data, the survey was modified accordingly and placed on the Web using SurveyMonkey. Students were recruited for pa rticipation via paper flyers ad vertising the survey and its Web address. After obtaining University of Flor ida Institutional Review Board approval for the survey, the investigator distributed the flyers to students in classe s in the colleges of Journalism and Communications, Liberal Arts and Sciences Health and Human Performance, and Health and Health Professions, and to one campus sorority. Each flyer included a unique, random number that the participant need ed to access the online survey. This step was designed to ensure that each participant t ook the survey only once, as no identifying information (e.g., name, student identification number, email address) was coll ected. The survey took approximately 15 minutes to complete. Respondents were not compensate d for completing the survey, although they each received two to three small pieces of candy upon r ecruitment. They also had the opportunity to increase their knowledge about the HPV vaccine vi a a link to a CDC Web pa ge at the end of the survey. The survey was open from April 17 thr ough June 8, 2009, and yielded 127 respondents out of 415 recruitsa response rate of 30.6%. Twelve of the submitted surveys (11.8%) were rejected as invalid or unusable. (Five responde nts were over the age of age 29, and therefore ineligible to participate. Seven respondents did not answer 75100% of the questions, rendering
47 their data unusable.) Eight respondents were be tween the ages of 27 and 29. These women were within the vaccines recommended age group wh en the vaccine became available in June 2006. Therefore, their data was considered relevant for this study. Data fr om 112 respondents were included in the final analysis. Descriptive Information Of the sample population ( n = 112 ) 93% were ages 1826 (84% < age 23) and 71% were undergraduates. ( See Table 3-1. ) Sixty-four percent were wh ite, 14% African American, 9% Hispanic, and 8% Asian. The sample populations r acial/ethnic profile is co mparable to that of the University of Floridas female student population. In the fall of 2008, among all female students ( n = 27,756), 61% were white, 13% Hispanic, 10% African American, and 8% Asian (University of Florida, 2008b). Differences may be due to over-sampling among specific academic programs, i.e., health education. Forty-three percent of respondents reported an annua l income of less than $25,000. Seventy-one percent stated that they used their own computer to complete the survey; 18% used a public computer, such as those found in comput er labs on campus. Fifty-one percent identified as moderately liberal or strongl y liberal on social issues, 20% as neutral or independent, and 29% as moderately conservative or strongly cons ervative. Forty-nine percent reported being moderately or very religious. Ei ghty-four percent of respondents had health insurance, and 68% had a primary care provider. Sixty percent had ha d a gynecological exam in the past 12 months. Eighty-four percent reported havi ng ever engaged in oral sex or sexual intercours e. Forty-three respondents (38%) had received the HPV vaccine (a t least one injection out of the required three).
48 Dependent Variable The dependent variable in this study was v accination status. A single variable was created from two survey questions: Have you received the HPV vaccine? (Yes/No) and Do you want to get the HPV vaccine? (Yes/No/Undecided). Res pondents were classified into four groups and assigned a corresponding value on a scale of 03. The categories were : 0) Does not want to get the vaccine; 1) Undecided about getting the vaccine; 2) Wants to get the vaccine; and 3) Has received the vaccine. ( See Appendix B. ) This variable had a mean of 1.49 and a standard deviation of .67. Independent Variables Independent variables were divided into three groups: Demographics (controls), information-seeking behaviors, and beliefs and attitudes about the HPV vaccine. The demographics group was comprised of five singl e variables constructed from condensed survey data. ( See Appendix B. ) Variables were developed from rec onstructed demographic data in which respondents were divided into dichotomous groups largely equal in number. For each variable, minor, similar categories were collapsed into two major categories (e.g., white and nonwhite.) The purpose of this was to improve eas e of analysis by limiting the number of possible categories and to increase the likelihood that st atistically significant predictors would be revealed. Reconfigured demographic va riables were defined as follows: Race/ethnicity: white and not white (mean = .64; sd = .48); Annual income: above $25,000 and below $25,000 (mean = .57; sd = .50); Social issue ideology: liberal or neut ral/conservative (mean = .51; sd = .50); Religiosity: religious or not relig ious (mean = .50; sd = .50); and Sexual experience: has had oral sex or sexual in tercourse or has not (mean = .84; sd = .37). The information-seeking behavior variables were comprised of four i ndices. The first index summed together respondents use of six medi a sources (newspapers, magazines, local TV,
49 national TV, blogs, and Web sites of official me dical organizations) for information about the HPV vaccine. Respondents were asked to rate th eir level of use on a fi ve-point scale ranging from never to always. This scale has a Cronbachs alpha of .81 (mean = 13.13; sd = 4.66). A second, similar index summed respondents frequenc y of use of the same six media sources for information about health issues in general. This scale has a Cronbach s alpha of .95 (mean = 15.72; sd = 4.63). The third index summed toge ther respondents perceived knowledgeability about HPV and confidence in their ability to pr otect against infection on a five-point scale ranging from not at all to v ery. These two measures have a Pearson correlation coefficient of .34 ( p < .05). The fourth index summed together respondents communi cation about the HPV vaccine with four interpersonal sources (peers, health care providers, family members, and boyfriends/girlfriends/spouses). Respondents we re asked to rate the frequency of their communication on a five-point scale, ranging fr om never to always. This scale has a Cronbachs alpha of .84 (mean = 7.12; sd = 2.44). The belief and attitude vari ables included two indices and one single variable. The first index summed together respondents belief in the HPV vaccines safety and in the trustworthiness of information a bout the vaccine. Respondents were asked to rate their level of agreement on a five-point scale ranging from strongly disagree to strongly agree if they believed that the vaccine is safe and that they could trust information about the vaccine presented in Gardasil advertisements and in the news medi a. (A primary focus of the information provided in Gardasil advertisements and in the news me dia is the vaccines safety.) This scale has a Cronbachs alpha of .76 (mean = 11.15; sd = 1.81). The second index summed together respondents beliefs about how th eir peers would judge them on the issue of HPV vaccination. Respondents were asked to rate their level of agreement on a five-point scale ranging from
50 strongly disagree to strongly agree if they believed that their peers would judge them negatively and that thei r boyfriend/girlfriend/spo use would no longer trust them if they got the vaccine. This scale has a Pearson correlation coefficient of .60 ( p < .05) (mean = 3.34; sd = 1.75). The final, single variable measured respon dents level of agreemen t on a five-point scale ranging from strongly disagree to strongly agree if they believed that their family would be supportive of them getting the HPV vaccine (mean = 1.49; sd = .67). These variables and indices were developed sp ecifically to test th e Theory of Planned Behavior. The trio of determinants were refl ected and operationalized within the independent variables. The belief and attitude variables were used to measure how attitude toward vaccination influenced intention. The same variables were also used to test how subjective norms influenced intention. Media-specific influen ces were included within thes e variables, both as a possible factor in the development of attitudes and s ubjective norms and as a direct influence upon behavior. Demographic variablesspecifically, income level and insurance statusmeasured how perceived behavioral control influenced intention. Each of th ese independent variables were analyzed through hierarchical regr ession analysis to determine how they contributed to intention to be vaccinated and, ultimately, positive vaccination status.
51 Table 3-1. Demographic inform ation about survey respondents Demographic indicator Percent Frequency Age 1819 13.4% 15 2021 44.6% 50 2223 26.0% 29 2425 5.3% 6 2629 10.7% 12 Year in school Freshman 4.5% 5 Sophomore 9.8% 11 Junior 25% 28 Senior 32.1% 36 Graduate or professiona l degree student 28.6% 32 Race/ethnicity White 64.3% 72 Black/African American 14.3% 16 Hispanic/Latino 8.9% 10 Asian/Asian American 8.0% 9 All other races/ethnicities 4.5% 5 Income level Less than $10,000 27.7% 31 $10,000$25,000 15.2% 17 $25,000$50,000 17% 19 $50,000$100,000 12.5% 14 $100,000$200,000 18% 20 $200,000+ 9.8% 11 Computer used to complete survey Own computer 70.5% 79 Public computer (like in a computer lab) 18% 20 Office or work computer 7.1% 8 Familys computer 4.5% 5 Social ideology Strongly conservative 3.6% 4 Moderately conservative 25% 28 Neutral or independent 20.5% 23 Moderately liberal 35.7% 40 Strongly liberal 15.2% 17
52 Table 3-1. Continued Demographic indicator Percent Frequency Religiosity Very religious 9.8% 11 Moderately religious 39.3% 44 A little religious 32.1% 36 Not at all religious 16.1% 18 I dont know 2.7% 3 Health insurance status Has health insurance 83.9% 94 Does not have health insurance 15.2% 17 Primary care provider status Has primary care provider 67.9% 76 Does not have primary care provider 21.4% 24 Does not know 10.7% 12 HPV vaccination status Has received any part of the HPV vaccine (one to three shots) 38.4% 43 Has not received any part of the HPV vaccine 61.6% 69 n = 112
53 CHAPTER 4 RESULTS This study addressed the knowledge, beliefs, a ttitudes, and behaviors of college women ages 1826 regarding HPV vaccination. Results were tabulated and analyzed using quantitative statistical methods including cal culation of frequency rates and hierarchical linear regression with SPSS predictive analytics software. RQ1: What Do College Women Ages 1826 Know About HPV and Its Vaccine? Three true/false questions about HPV and the HPV vaccine and two questions measuring general awareness about Gardasil were tested for real knowledge. The ma jority of respondents answered the true/false questi ons correctly. On two of the que stions, at least 98% answered correctly, and on the third, 74% selected the right answer. (See Table 4-1.) The responses to the yes/no general awareness questions were al so overwhelmingly posit ive (97% and 72% of respondents indicated they were aware of the information being presented). Two other questions tested for perceived knowledge about HPV. When asked how mu ch they felt they knew about HPV, 71% reported having at least some knowledge Asked how confident they felt in their ability to protect themselves against HPV, 93% reported being at least moderately confident. RQ2: What Are Their Beliefs and Attitudes Regarding the HPV Vaccine? Respondents were asked to rate their level of agreement with a variety of belief and attitude statements. Fifty percent of respondents said that they we re not at risk for getting HPV and were not worried about getti ng HPV and/or cervical cancer, 31% said they were at risk and were worried, and 16% were undecided. ( See Table 4-2. ) Eighty-five percent agreed that the HPV vaccine can help protect them against cervi cal cancer, and 61% agreed that the vaccine is safe. Seventy-eight percent said that their fa milies would be supportive of them getting the HPV vaccine. Eighty-one percent said they were not afraid that other people would judge them
54 negatively if they got the vaccine, and 88% said that getting the vaccine would not lead their partner (boyfriend/girlfriend/spouse) to distrust them. Fifty-four percent said they believed that information presented in the news media about the HPV vaccine is accurate, while 43% were undecided. Sixty-eight percent said they believed that information presented in advertisements for Gardasil is accurate. Fifty-eight percent agreed that information from the mainstream news media influences their health decisions; 40% said the same of information presented in advertisements. When asked their overall im pression of the HPV vaccine, 71% said it was positive, 3% said it was negative, and 26% were undecided. RQ3: What Are Their Main Sources of Information About HPV and the HPV Vaccine? When participants were asked to identify their most likely sources of information on health issues in general, 77% sa id they would ask thei r doctor, and 77% said they would look it up using an Internet search engine. ( See Table 4-3. ) Sixty-four percent indicated they would ask a family member, 60% would look it up on the Web site of an official medical organization, and 46% would ask a friend. When asked to select the sources from wh ich they received the majority of their information about HPV, 58% of respondents listed their doctor, 54% chose advertisements, and 53% named the mainstream news media (inclu ding online sources). Other sources included family members (34%) and official medical organizations, like the CDC (30%). ( See Table 4-4. ) When asked which sources had provided them with the most information about the HPV vaccine, 61% said advertisements, 60% said their doctor, 46% said the mainstream news media, and 32% said family members. ( See Table 4-5. ) When respondents were asked specifically which mass media sources had provided them with the most information about the HPV vaccine, the top three choices were television (77%), advertisements (31%), and magazines (30%). ( See Table 4-6. ) Ninety percent of respondents
55 reported having seen advertisements for Gardas il on television, 69% saw them in magazines, 55% saw them in their doctors office, 38% saw them online, and 35% saw them at the student health clinic. ( See Table 4-7. ) Respondents were asked to rate on a one to fi ve scale how frequently they talked with various interpersonal sources about the HPV vaccine. ( See Table 4-8. ) Peers had the greatest mean frequency of use (2.45), followed by family members (2.37), doctors and other health care providers (2.30), and partners ( boyfriend/girlfriend/spouse) (1.76). ( See Figure 4-1. ) All of these responses were below the midpoint of the scale. Using the same scale, respondents were also asked to rate how frequently they used various types of mass media for in formation about the HPV vaccine a nd health issues in general. ( See Table 4-9. ) For information about the HPV vaccine, Web sites of official medical organizations such as the CDC had the greate st mean frequency of use (2.67), followed by national TV stations (2.48), magazines (online or print) (2.29), loca l TV stations (2.10), newspapers (online or print) (1.88), and blogs (1.67). ( See Figure 4-2. ) For information about health issues in general, Web sites of official medical organi zations again came out on top, with a mean frequency of 3.41, followed by nationa l TV stations (2.78), magazines (2.75), newspapers (2.57), local TV sta tions (2.26), and blogs (1.98). ( See Table 4-10 and Figure 4-3. ) RQ4: What Has Most Influenced Their D ecision-Making Regarding HPV Vaccination? Research question four was designed to de termine which factors had most influenced respondents HPV vaccination decisions. For responde nts who indicated that they had decided to get the HPV vaccine or had already been vaccinated ( n = 65), 97% said pr otection against HPV was the factor that had most influenced their decision. Other influential factors included their belief that the vaccine is effective (75%) a nd safe (68%), that the vaccine had been
56 recommended by their family (63%) or doctor (6 2%), and that the vaccine was easy to get (52%). ( See Table 4-11. ) Among respondents who said they had deci ded against getting the HPV vaccine ( n = 11), eight said that their belief that they were not at risk for HPV had influenced their decision. Four said they were not worried about getting HPV a nd/or cervical cancer, and three said that they believed the vaccine is unnecessary. ( See Table 4-12. ) Among respondents who indicated they were undecided about whether to get the HPV vaccine ( n = 35), 77% said that the cost of the vaccine was a factor that is likely to influence their eventual decision regarding HPV vaccinatio n. Other potentially influe ntial factors were the recommendation of the vaccine by their doctor (74%), the safety of the vaccine (74%), their personal risk of getting HPV and/ or cervical cancer (66%), the effectiveness of the vaccine (63%), and their level of concern about ge tting HPV and/or cervical cancer (54%). ( See Table 413. ) All respondents were asked to indicate which media sources most influenced their decision regarding HPV vaccinati on. Forty-seven percent said advertisements for Gardasil (in print, on television, or online) and 35% said news articles (in newspa pers or magazines, either in print or online) had influenced them. ( See Table 4-14. ) RQ5: How Have Their Knowledg e, Beliefs, Attitudes, and Ot her Factors Influenced Their Behavior Regarding HPV Vaccination? To assess how respondents knowledge, beliefs, attitudes, and other factors influenced their behavior, a hierarchical linear regression predicting intention to get the HPV vaccine was conducted. The dependent variable was positive v accination status or desire to receive the vaccine.
57 The first block (race/ethnicity, annual inco me, social ideology, re ligiosity, and sexual experience) looked at control variables (demogra phics) and accounted for 14.1% of the variance. ( See Table 4-15. ) Within the TPB model, the annual inco me variable tested whether perceived behavioral control affected inte ntion and behavior. The second block (media use frequency for HPV vaccine information; media use frequency fo r health information; perceived knowledge and self-confidence about HPV and its vaccine; and interpersonal communication about the HPV vaccine) focused on information-seeking behavior and accounted for 12.4% of the variance. When the block was entered into the analys is, interpersonal communication about the HPV vaccine (beta =.41) was a significant predictor ( p < .01) of individual intention to get vaccinated. In the third block (trust of HP V vaccine safety and information; peer judgment regarding the HPV vaccine; and family support), beliefs and at titudes regarding the vaccine were added and accounted for 16.4% of the variance. Within the TPB model, the peer judgment and family support variablesalong with the interpersonal communicati on variable from the second blocktested whether subjective norms affected vaccination intention and behavior. Also, the safety/trustworthiness variable tested how attitu des toward HPV vaccination influenced intention and behavior. When the third block was entered into the model, interpersonal communication about the HPV vaccine (beta = .24) remained a significant predictor ( p < .05), along with family support (beta = .27, p < .05). The most significant predictor of intention to be vaccinated was trust of HPV vaccine safety and related information (beta = .29, p < .01). The independent variables included in the regres sion accounted for 42.7% of the va riance in individual intention to be vaccinated.
58 Table 4-1. Real and perceived knowle dge about HPV and the HPV vaccine Correctly answered true/false questions about HPV vaccine Percent HPV is the most common sexually transmitted disease. (True) 74% (84) HPV is linked to genital warts and cervical cancer. (True) 99% (112) Ideally, women should be given the HPV vaccine before they become sexually active. (True) 98% (111) Indicated basic awareness about HPV vaccine. Have you heard of the HPV vaccine Gardasil? (Yes) 97% (110) Did you know that Gardasil is the only FDA-approved HP V vaccine available in the U.S.? (Yes) 72% (81) How much do you feel you know about HPV (Human Papillomavirus)? Very knowledgeable 10% (11) Knowledgeable 24% (27) Some knowledge 38% (43) Little knowledge 23% (26) No knowledge 5% (5) How confident do you feel in your abili ty to protect yourself against HPV? Very confident 25% (28) Confident 38% (42) Moderately confident 30% (34) Little confidence 5% (6) No confidence 2% (2) Values rounded to the nearest whole percentage. Table 4-2. Beliefs and attitude s about HPV and the HPV vaccine Please rate your level of agreement with the following statements. Agree Disagree Undecided Safety and assurance index The HPV vaccine is safe. 61% (68)4% (4) 35% (40) I believe that the information presented in the news media about the HPV vaccine is accurate. 54% (60)3% (3) 43% (48) I believe that the information presented in advertisements for the HPV vaccine Gardasil is accurate. 68% (75)3% (3) 29% (32) Peer judgment index I am afraid people will judge me negatively if I get the HPV vaccine. 12% (13)81% (91) 7% (8) My partner (boyfriend/girlfrie nd/spouse) will not trust me if I get the HPV vaccine. 4% (4)88% (99) 8% (9)
59 Table 4-2. Continued Please rate your level of agreement with the following statements. Agree Disagree Undecided Other assessed beliefs and attitudes My family would be supportive of me getting the HPV vaccine. 78% (87)5% (6) 17% (19) I am at risk for getting HPV. 31% (35)53% (59) 16% (18) I am worried about getting HPV and/or cervical cancer. 31% (35)50% (55) 19% (21) The HPV vaccine can help protect me against cervical cancer. 85% (93)9% (10) 6% (6) Information from the mainstream news media influences my health decisions. 58% (65)22% (25) 20% (22) Information presented in advertisements influences my health decisions. 40% (44)36% (40) 24% (27) Positive Negative Undecided My overall impression of the HPV vaccine is: 71% (78)3% (3) 26% (29) Values rounded to the nearest whole percentage. Table 4-3. Sources of inform ation about health issues Rank When I have a question about a health issue, I am most likely to:* Percent Frequency 1 Ask my doctor 77% 86 1 Look it up using an Internet se arch engine, like Google 77% 86 2 Ask a family member 64% 72 3 Look it up on the Web site of an official medical organization, like the Centers for Disease Control and Prevention 60% 67 4 Ask a friend 46% 52 Values rounded to the nearest whole percentage. Respondents asked to select all that apply.
60 Table 4-4. Sources of information about HPV Rank The majority of my information about HPV has come from:* Percent Frequency 1 My doctor 58% 65 2 Advertisements 54% 60 3 Mainstream news media, including online sources 53% 59 4 Family members 34% 38 5 Official medical organi zations, like the CDC 30% 34 Values rounded to the nearest whole percentage. Respondents asked to select all that apply. Table 4-5. Sources of info rmation about HPV vaccine Rank The majority of my information about the HPV vaccine has come from:* Percent Frequency 1 Advertisements 61% 68 2 My doctor 60% 67 3 Mainstream news media, including online sources 46% 51 4 Family members 32% 36 Values rounded to the nearest whole percentage. Respondents asked to select all that apply. Table 4-6. Mass media sources of information about HPV vaccine Rank What type of mass media has provided you with the most information about the HPV vaccine?* Percent Frequency 1 Television 77% 86 2 Advertisements 31% 35 3 Magazines 30% 33 Values rounded to the nearest whole percentage. Respondents asked to select all that apply. Table 4-7. Observed locations of Gardasil advertisements Rank Where have you seen advertisements for Gardasil?* Percent Frequency 1 On television 90% 101 2 In magazines 69% 77 3 In my doctors office 55% 61 4 Online 38% 43 5 At the student health clinic 35% 39 Values rounded to the nearest whole percentage. Respondents asked to select all that apply.
61 Table 4-8. Interpersonal sources of information about HPV vaccine How often have you talked with the following people about the HPV vaccine? Never Rarely Occasionally Frequently Always Peers 15% (17)35% (39)41% (46)8% (9) 1% (1) Doctor or other health care provider 31% (35)20% (22)37% (42)11% (12) 1% (1) Family members 23% (26)27% (30)40% (45)10% (11) 0% (0) Partner (boyfriend/girlfriend/spouse) 53% (59)23% (26)19% (21)4% (4) 1% (1) Values rounded to the nearest whole percentage. 2.30 2.37 1.76 2.45 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 PeersHealth care providersFamily membersPartner Interpersonal SourceMean Use Figure 4-1. Mean frequency of talking with inte rpersonal sources about HPV vaccine. (Note: 1 = Never, 2 = Rarely, 3 = Occasiona lly, 4 = Frequently, 5 = Always)
62 Table 4-9. Frequency of media use for HPV information How often do you use the following types of media for information about the HPV vaccine? Never Rarely Occasionally Frequently Always Newspapers (online or print) 42% (47)32% (36)22% (24)2% (2) 2% (2) Magazines (online or print) 28% ( 30)29% (32)31% (34)10% (11) 2% (2) Local TV stations 38% (42)27% (30)24% (26)7% (8) 4% (4) National TV stations 22% (24)27% (30)33% (36)15% (16) 3% (3) Blogs 57% (62)25% (27)13% (14)3% (3) 2% (2) Web sites of official medical organizations 26% (29)16% (18)31% (34)19% (21) 8% (9) Values rounded to the nearest whole percentage. 2.29 2.10 2.48 1.67 2.67 1.88 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Newspapers (online or print) Magazines (online or print) Local TV stations National TV stations BlogsWebsites of official medical organizations Media SourceMean Use Figure 4-2. Mean frequency of media use for HP V vaccine information. (Note: 1 = Never, 2 = Rarely, 3 = Occasionally, 4 = Frequently, 5 = Always)
63 Table 4-10. Frequency of medi a use for health information How often do you use the following types of media for information about health issues in general? Never Rarely OccasionallyFrequently Always Newspapers (online or print) 24% ( 27)23% (25)26% (29)24% (26) 3% (3) Magazines (online or print) 22% (24)17% (19)30% (33)25% (28) 6% (6) Local TV stations 29% (32)32% (35)23% (25)15% (16) 1% (1) National TV stations 16% (17)20% (22)35% (38)28% (30) 1% (1) Blogs 48% (53)21% (23)17% (19)12% (13) 2% (2) Web sites of official medical organization 7% (7)15% (16)28% (31)32% (35) 18% (20) Values rounded to the nearest whole percentage. 2.75 2.26 2.78 1.98 3.41 2.57 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Newspapers (online or print) Magazines (online or print) Local TV stations National TV stations BlogsWebsites of official medical organizations Media SourceMean Use Figure 4-3. Mean frequency of media use for health information in general. (Note: 1 = Never, 2 = Rarely, 3 = Occasionally, 4 = Frequently, 5 = Always)
64 Table 4-11. Primary influences on decision to get HPV vaccine Rank What factors most influenced your decision in favor of getting the HPV vaccine?* Percent Frequency 1 I want to protect myself against HPV 97% 63 2 I believe the vaccine is effective 75% 49 3 I believe the vaccine is safe 68% 44 4 My family said I should 63% 41 5 My doctor recommended it 62% 40 6 The vaccine is easy to get 52% 34 n = 65 Respondents asked to select all that apply. Table 4-12. Primary influences on decision to not get HPV vaccine Rank What factors most influenced your decision against getting the HPV vaccine?* Percent Frequency 1 I am not at risk for HPV 73% 8 2 Im not worried about getting HPV and/or cervical cancer 36% 4 3 I believe that it is an unnecessary vaccine 27% 3 n = 11 Respondents asked to select all that apply. Table 4-13. Primary influences on futu re decision regarding HPV vaccination Rank What factors are most likely to influence your eventual decision regarding the HPV vaccine?* Percent Frequency 1 The cost of the vaccine 77% 27 2 The recommendation of my doctor 74% 26 2 The safety of the vaccine 74% 26 3 My personal risk of getting HP V and/or cervical cancer 66% 23 4 The effectiveness of the vaccine 63% 22 5 My level of concern about getti ng HPV and/or cervical cancer 54% 19 n = 35 Respondents asked to select all that apply. Table 4-14. Media sources that have mo st influenced HPV vaccination decision Rank Of the following media sources, which have most influenced your decision about whether to get the HPV vaccine?* Percent Frequency 1 Advertisements for Gardasil (in pr int, on television, or online) 47% 53 2 News articles (in newspapers or magazines, either online or in print) 35% 39 n = 112 Respondents asked to select all that apply.
65 Table 4-15. Hierarchical linear regression predicting individual intention to get HPV vaccine = p < .05 ** = p < .01 Independent variables Standard ized beta coefficients Incremental R Block 1: Race/ethnicity .14 .12 Annual income .19 .14 .12 Social issue ideology .20 .15 .07 Religiosity .09 .10 .03 Sexual experience .13 .06 .02 14.1% Block 2: Media use frequency for HPV vaccine information -.03 .00 Media use frequency for health information .05 -.06 Perceived HPV knowledge and self-confidence .12 .07 Interpersonal communication about HPV vaccine .41** .24* 12.4% Block 3: Trust of vaccine safety and information .29** Peer judgment .03 Family support .27* 16.4% Total Variance (R) 42.7%
66 CHAPTER 5 DISCUSSION This study revealed several statistically si gnificant factors predic ting college womens intention to be vaccinated against HPV. The th ree key findings were that 1) belief in HPV vaccine safety and trust in its related informati on, 2) family support regarding vaccination, and 3) interpersonal sources of information about HPV all predicted likelihood of vaccination intention. The greater the level of belief in vaccine safety/information trustworthiness, level of perceived family support, and frequency with which the res pondent used interpersona l sources, the greater the likelihood that she would either want to be vaccinated or would have done so already. Sixty percent of the sample population said they either wanted to get the HPV vaccine or had already received it. The mo st significant predictor of vaccination intention was belief in vaccine safety and in the trustworthiness of rela ted information presented in advertisements and the news media. Respondents who said they believ ed that the HPV vaccine is safe and that they trusted information about the vaccine presented in Gardasil advertisemen ts and the news media were more likely to want to be (or to have al ready been) vaccinated. These findings suggest that belief in vaccine safety and belief in the trustw orthiness of vaccine info rmation relate to one another through message reinfo rcement. Information presented not only in Gardasil advertisements but also in much of the related mainstream news coverage focuses on the safety, effectiveness, and necessity of the vaccine. Re spondents trust in these information sources reinforced their belief in the safety of the HPV vaccine. (Indeed, when respondents who expressed a desire to be vaccinated were aske d what had most influenced their decision, 97% said they wanted to protect themselves against HPV; 75% said they believed the vaccine is effective; and 68% said they believed the vacc ine is safe.) Interestingly, media use was not a predictive factor in this analysis ; in fact, respondents did not indi cate the media as a top source of
67 information on HPV, the HPV vaccine, or health i ssues in general. The frequency of media use for information on these topics was consiste ntly lowusually rangi ng between never and occasionally. Yet, this populati on felt a significant level of tr ust in the medias HPV vaccinerelated informationif and when they encountered it. The beliefs and attitudes measured in this safety/trustworthiness index were strongly correlated with overall impression of the HPV vacci ne: The higher the level of agreement in the belief that the vaccine is safe and that its rela ted information sources can be trusted, the more positive the respondents impression of the vaccine. Some of these findings are consistent with those of other researchers (D Urso, Thompson-Robinson, & Cha ndler, 2007; Rouner & Lindsey, 2006), who found that the mass media were not a primary source of information about STDs and/or HPV for young adult women. It was not surp rising, therefore, that the current sample population reported low levels of media use. HINTS (2008) found, however, that the general population has only low to moderate levels of trus t in the media for information about health or medical issues. The current studywhich examin ed a narrower population than that studied by HINTSfound much higher levels of trust in the media for HPV vaccine information. These results raise the question of whether the respondents were especially trusting of Gardasil advertisements and vaccine-related news media, even if they had low exposure to those sources, or whether they were so informati on-savvy about HPV and its vaccine that media sources served only to confirm their previously held knowledge and beliefs. Contrary to earlier findings about young womens lack of awareness a bout HPV and STDs in general (Baer, Allen, & Braun, 2000; DUrso, Thompson-Robinson, & Ch andler, 2007), this sample population was remarkably well-informed about HPV and th e HPV vaccine. The majority of respondents answered the basic HPV knowledge and awarene ss questions correctly. As found by Jones and
68 Cook (2008), real knowledge was not a statisti cally significant predic tor of respondents intention to be vaccinated. However, because th ere was so little variance in the respondents knowledge levels, this may have obscured the analysis. Schiffner and Buki (2006) theorized that low levels of awareness about STDs, including HP V, contribute to a l ack of self-protective behaviors among college-age women. This population, by contrast, appeared to have high levels of both awareness and self-effi cacy: 72% reported being at leas t somewhat knowledgeable about HPV, 63% expressed confidence in their ability to protect themselves against infection, and 60% either wanted to get the vaccine or had alrea dy received it. The first two variables should be interpreted with caution, since high levels of pe rceived knowledge and ability may reflect a false sense of confidence. However, the fact that the majority of respondents e xpressed intention to be vaccinated suggests that the group was, overall, empowered and informed. Several factors may contribute to these hi gher levels of real and perceived knowledge. Firstly, 90% of respondents reported having seen Gardasil advertisements on television. These ads have likely served to educate young wome n about HPV and reinforce messages about the vaccines necessity, safety, and effectiveness. (This finding is confirmed by a HINTS study showing a 30% jump in public awareness about HPVs link to cervical cancer in the two years after Gardasil hit the market.) Secondly, Gardasil is a relatively new pr oduct, and both it and HPV appear to have received more media covera ge during the past three years than most other STDs combined, with the likely exception of HIV/AIDS. The novelty of an STD-prevention vaccinedesigned just for womenhas proba bly attracted some young women who would otherwise not have paid atte ntion to an STD-related adve rtisement or news story. The respondents did not seem to have been negativel y influenced by recent media coverage about the questioned safety of childhood vaccinations. Of the 108 respondents who chose to answer the
69 open-ended question about their feelings on vacci nes in general, 86 offered positive statements about vaccines necessity and/or safety (e.g., I feel they are g ood and very influential in the world; I feel they are necessa ry in todays society). Negati ve responses touched on potential side effects, lack of information, and the pain of injections. Only one respondent mentioned autism in relation to childhood vaccinations. It a ppears that negative messages about vaccine safety have not influenced this population, perh aps because many of the concerns do not relate directly to them or their health. Another factor predictive of vaccinati on intention was family supportrespondents belief that their family members would be supportive of them getting the vaccine. This may appear unusual, given that the sa mple population is made up of a dults and that the vaccine is designed to protect against an STDa topic th at some families may feel uncomfortable discussing. However, it is important to consid er how the vaccine has been framed in both Gardasil advertisements and in news coverage. First and foremost, it is presented as a cancerprevention vaccine. Gardasil advertisements urge young women (and/or their parents) to protect (themselves) against cervical cancer and other HPV diseases (Gardasil.com, 2009). The ads discuss HPV not as an STD but simply as a di sease. This rhetoricl argely echoed in news media coveragemay make families more likely to discuss the vaccine, and for young adult women to feel that they would be supported in their decision to be vaccinated. High levels of perceived family support may also suggest that the respondents communicated openly with their families about the vaccine and its related issues, and that the womens familiesor at least their motherswere aware that their daughters are (or will be) sexually active. However, for families who are uncomfortable with this topic, frami ng Gardasil as a cancer preventative may remove some of the unease and allow for more open dial ogue. In contrast to family support, peer
70 reactions appeared to ha ve little impact on the re spondents. Most of them disagreed that they would be judged negatively by their peers or boyfri end/girlfriend/spouse if they got the vaccine. Ultimately, the respondents felt they would be bol stered by family support in their vaccination decision and would not be deterre d by negative peer pressure. A related factor, interpersonal sources of information about the HPV vaccine, was also a significant predictor of vaccinati on intention. These sources include d peers, family members, and doctors or other health care professionals. Pa radoxically, respondents al so reported low use of these sources for HPV information. Mean use fre quencies ranged from nev er to rarely. As demonstrated similarly with the safety/trustwort hiness index, it appears that the respondents did not often engage in interpersonal communication about the vaccine, but when they did, it had a significant impact. These results ar e consistent with previous st udies showing that young women prefer to receive information about STDs from interpersonal information sources (including health care providers, friends, mothers, and wome n who have had an STD), largely due to the perception that those sources are trustworthy, knowledgeable, and supportive (McCree, Sharpe, Brandt, & Robertson, 2006; Rouner & Lindsey, 2006). They are also consistent with the findings of Jones and Cook (2008), who reported that college students were more likely to want the HPV vaccine if it was recommended by a do ctor, spouse, parent, or friend. The fact that the current sample population sp ent so little time talki ng with interpersonal sources about the vaccine yet was motivated to ward vaccination when it did suggests a selffulfilling tendency. The participants may have been more likely to talk with people who shared their views about the vaccine or w ho could confirm or contribute to their previously held beliefs and knowledge about it. Therefor e, a single conversation with a trusted interpersonal source could serve as the tipping point toward the decision to be vaccin ated. Because the participants
71 were highly informed about the HP V vaccine it is unlikely that they sought out friends, family members, and health care providers as primary in formation sources; rather, these sources served as trusted confidants who could help reinforce the womens vaccination decisions. Overall, these results suggest that the decision to get vaccinat ed was not a difficult one. Those who had decided in favor of vaccination did not require much convin cinga factor that could be explored in more depth in future studies assessing the persuasive role of Gardasil advertisements or of other information sources. The behavior prediction model presented th rough the Theory of Planned Behavior is largely upheld in these results. Firstly, belief in the safety of the vaccine and in the trustworthiness of related information presen ted by advertisements and the news media was correlated with an overall positive impression of the vaccine. This attitude predicted a desire (intention) to be vaccinated. Secondly, family me mbers, peers, and other interpersonal sources contributed to a belief that other people suppor ted the respondents va ccination decisions. This subjective norm also predicted intention to be vaccinated. The third traditional determinant of behavior, perceived behavioral control, was not represented in the findings. There were no significant results based on income level, insura nce status, primary care provider status, or any other potential barrier to access. However, beca use of their status as college students, the respondents likely faced fewer ba rriers to access that hinder ot her segments of the population. (Eighty-four percent of responde nts reported having health insu rance and 68% reported having a primary care provider. By contrast, about 73% of U.S. adults ages 1834 had insurance in 2007 (U.S. Census Bureau, 2007).) Based upon the specific characteristics of the sample population, the TPB model was supported. Behavioral, normative, and control be liefs and their related attitudes, subjective
72 norms, and perceived behavioral co ntrols were all tested for their ability to predict vaccination intention. The influence of the mass media was also included throughout the model. Two of the three determinants (attitudes and subjective norms plus the media) proved significant in their ability to predict intention, and the absence of the third determinant (perceived behavioral controls) may simply reinforce the strength of the first two. Despite their relatively limited use of media and interpersonal sources for information about HPV, the sample population proved to be highly knowledgeable about the disease and vaccine and empowered in its ability to consider and seek out vaccination. The TPB states that behavior al, normative, and control beliefs feed into one another, as well as contributing to related attitudes and behaviors. Perceived behavioral controls may have been circumvented because knowledge a bout Gardasil, beliefs and attitudes about the vaccines safety, and the support of family memb ers and other interpersonal sources were so strong. Perceived behavioral controls also may have been overshadowed by the influence of the mass media as a trusted source of information about the vaccine. This trust he lped drive belief in the vaccines safety and an overall positive impression about the vaccine, which in turn contributed to a positive intention to be vaccinated. Further studies may expand upon the influence of the mass media as both an indir ect and direct determinant of HPV vaccination intention and behavior. Limitations This studys primary lim itation centers on its samp le population. The size ( n = 112) was relatively small and the sample was not random; this limits the generalizability of the results. The samples racial/ethnic profile was, however, very similar to that of the University of Floridas student body. Another concern is the broad age range included in the sample. Women ages 18 to 29 may have significant differences in maturity, health awarene ss and behaviors, income, selfefficacy, and more. The study may have benefited from narrowing in on one particular adult age
73 group, e.g., older adolescents ages 1821. Despit e this potential lim itation, age was not a statistically significant pr edictor of vaccination inte ntion in the current study. Although students from a variety of classe s were recruited, over-sampling probably occurred among students in the College of Health and Human Performance. Self-selection bias was a likely factor, in that student s interested in health education may have a greater interest in and awareness of issues such as the HPV v accine. Also, although compensation was equal (and minimal) for all recruits, some professors en couraged their students to participate more enthusiastically than others. This appeared to occur most often in health-related classes. Evidence of self-selection bias may be reflected in the respondents high level of knowledge about the HPV vaccine. Women who knew more about the vacci ne might have been more willing to take the survey. Howe ver, the fact that 90% of respondents reported having seen Gardasil advertisements on television suggests th at women of various interests and backgrounds have been exposed to basic information about the HPV vaccine. Mitigating some of the self-selection bias wa s the high rate of response from one campus sorority, which included women fr om a variety of degree programs. After the recruitment flyers were distributed among sorority members, the on line survey responses p eaked for several days. (The investigator estimates that at least 30 memb ers participated.) In th e interest of preserving complete anonymity, no potentially identifying information was collected. However, it would have been helpful to know the respondents academ ic majors in order to better control for selfselection and recruitment bias. While the anonymous nature of the survey may have encouraged some respondents to be more forthcoming, it also create d several limitations. Although car e was taken to ensure that respondents did not take the survey more than once, there is no way to guarantee that this type of
74 manipulation did not occur. The validity of the results is also vulnerable because the survey relied entirely upon self-reported data. Although th ere was no incentive to answer questions in any specific way, participants could have lied, exaggerated, responded carelessly, or misunderstood the questions. The dependent vari able used in the regression analysis vaccination status and desirew ould be especially harmed by such inaccuracies. Ideally, specific survey data would be confirmed via respo ndents medical records, perhaps as part of a study done in partnership with the student hea lth clinic. Recruitment for such a study would likely face considerable challenges unless mo re significant compensation was offered. Limitations in the evaluation tool were reve aled during analysis of the data. The survey provided the most information about women who had decided in favor of vaccination. The number of those who had decided against it was too small to allow for significant analysis; however, those who described them selves as undecided about th e vaccine represented 30% of the respondents. More in-depth data collection and analysis focused specifically on this population could have yielded results of particular interest to hea lth educators attempting to win over women who have not yet decided whether to be vaccinated. Another limitation in the survey design occurred in the questions rega rding mass media and interpersonal information sources. Questions focused on frequency of use not on how much the respondent valued those sources. The survey results suggest that alt hough the respondents spend little time using these information sources, they are significantly infl uenced by them. Asking the respondents to list their most valuable or trusted information so urces may have helped explain the seemingly paradoxical relationship between the respondents low use of the media and interpersonal information sources for information about the HPV vaccine and the influential effect these
75 sources had upon their decision to be vaccinated. It also may have yielded more thorough results applicable to testing the TP Bs subjective norm component. Despite its limitations, this st udy served its role as an e xploratory study. Given that the HPV vaccine is a recent medical development and has been available in the U.S. for only three years, there is a shortage of academic research on the topic and its related issues. This study serves as a springboard for future studies about the acceptance of the HPV vaccine not only among college women but adult women in general. Future Areas of Study Future research on this topi c should utilize a larger, random sample. If more detailed information is desired about the vaccination decisi ons of college students, additional and varied universities should be included. Perh aps more importantly, future research should look at the 1826-year-old population in genera lalong with women older than age 26rather than just focusing on college students. Significant differen ces may exist between those who are in college and those who are not regarding vaccination kno wledge, beliefs, attitudes, and decisions. A larger, more in-depth study would provide health educators with information on how to reach the vaccines target adult population as a whole. On the other hand, additional studies of select subpopulations may allow for more targeted, cu lturally appropriate outreach efforts. Because the HPV vaccine is still a relatively ne w product, future studies would also benefit from qualitative analysis to provide a more in-d epth look at respondents feelings and opinions on the vaccine. One group of particular interest is women who believe they are not at risk for HPV and therefore do not seek out vaccination. A better understanding of this perspective could help health educators and medical professionals more effectively address women who do not view themselves as good candidates for vaccina tion, based perhaps on incorrect information. The
76 survey results raise several ques tions that may be better examin ed through a mixed methods or qualitative approach. Although the vaccine is currently targeted onl y to girls and women, researchers need not be limited to these populations. With clinical tr ials ongoing, it is likely that the vaccine will one day be recommended to other groups. Potential ar eas for future study incl ude the appeal of HPV vaccination among women over the age of 30 and among boys and young adult men. Another key group for future study is women who describe themselves as undecided about the vaccine. Determining if and how they can be motivated to get vaccinated is an im portant step in achieving maximum vaccination coverage. As this study suggested, Gardasil advertisements may play an important role in reinforcing young womens beliefs and attit udes about the vaccine and imp acting their decision to get vaccinated. In order to better understand this infl uential factor there is a need for content analyses of Gardasil advertisement on television and in print, and also of the news medias reporting on the issue throughout th e last three years. Focus groups could also provide helpful input on how young women respond to Gardasil adve rtisements and/or related media coverage. Conclusion This study provides an important first step in the study of HPV vaccination intention among young adult women. The window of opportunity for similar research is limited; due to state and federal policies, it is likely that w ithin a decade, most young women will receive the HPV vaccine prior to turning 18 and assuming legal responsibility for their health care decisions. This unique time and topic has th e potential to provide health care educators with rich information about how to best reach and influe nce young adult women on a variety of sexual and reproductive health-related issues. This study fi lled a gap in knowle dge about how college women have responded to the availability of an HPV vaccine, and what factors most impact their
77 vaccination decisions. Using the Theory of Pl anned Behavior, key influences upon vaccination intention were discovered. The results sugge st that college wome n may be significantly influenced by HPV information provided by adver tisements, the news media, and interpersonal sourcesdespite the fact that re spondents reported relatively lo w use of these sources. The survey also revealed that the women were highly informed about the HPV vaccine. Their knowledge, combined with the information they ga ined from the news media and interpersonal sources, may have helped develop and/or reinfo rce their beliefs regarding HPV vaccine safety, which contributed directly to their decision to be vaccinated. These conclusions, along with the findings of future and related research, can he lp guide health educators and public health professionals as they work to promote HP V vaccination and eradic ate cervical cancer.
78 APPENDIX A SURVEY Informed Consent Protocol Title: HPV Vaccination Acceptance Among College Women Study Approved by University of Flor ida Institutional Review Board 02 Protocol #2009-U-0288 Please read this consent document carefully be fore you decide to participate in this study. Purpose of the research study: The purpose of this study is to examine knowledge, beliefs, attitudes, and decisions regarding th e Human Papillomavirus (HPV) vaccine. What you will be asked to do in the study: You will be asked to par ticipate in an anonymous online survey describing your knowledge, beliefs, attitudes, and decisi ons regarding the HPV vaccine. You can take the survey from any computer with Internet access. Time required: 15 minutes Risks and Benefits: There are no anticipated risks involved with this study. It is unlikely that you will benefit directly from participating. Compensation: No compensation is offered for comple ting the survey, other than the piece of candy given when you were recruited for participation. Confidentiality: Your identity will not be known by the researchers, as you will use the random access number provided to you to participate in the study. This number will not be linked to your name, email address, or any other identifying in formation. When you take the survey, your email and IP address will not be collected. Surveys w ill be decoupled from any such information. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. You may choos e to not answer any questions you wish. Right to withdraw from the study: You have the right to withdr aw from the study at any time without consequence. Whom to contact if you have questions about the study: Cory Armstrong, assistant professor, Department of Journalism, University of Flor ida, P.O. Box 118400, Gainesville, FL 32611, (352) 392-0847, or email@example.com; or Sara Hennebe rger, graduate student, Department of Journalism, firstname.lastname@example.org. Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gain esville, FL 32611-2250; phone (352) 392-0433.
79 1) I have read the procedure described ab ove. I voluntarily agree to participate in the procedure. I understand that I may prin t this page for my own records. I agree I do not agree. I will not participate in the study. 2) Please enter the five-d igit access number printed on your recruitment flyer. __________________ First, youll be asked to share so me basic information about yourself. 3) What is your sex? Female Male 4) What is your age? ____ 5) What is your student status? Freshman Sophomore Junior Senior Masters Doctoral Other: ____________________ 6) What is your race/ethnicity? American Indian or Alaskan Native Asian or Asian American Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Multiracial Other: ____________________ 7) What computer are you us ing to take this survey? My own computer A public computer (like in a computer lab or at a library) My familys computer My roommates or friends computer Other: ____________________
80 8) What is your annual income? (Or, if you are primarily supported by your parents, what is their annual income?) Less than $10,000 $10,000$25,000 $25,000$50,000 $50,000$100,000 $100,000$200,000 $200,000+ 9) In terms of social issues, do you consider yourself to be: Strongly conservative Moderately conservative Neutral or independent Moderately liberal Strongly liberal 10) How religious do you consider yourself to be? I dont know Not at all religious A little religious Moderately religious Very religious Next, youll be asked a few health questions. 11) Do you have health insurance? Yes No 12) Do you have a primary care provider? Yes No 13) Have you had a gynecological exam in the past 12 months? Yes No 14) Have you received the HPV (Human Pa pillomavirus) vaccine (all three shots)? (If yes, skip to question 16.) Yes No 15) Have you received part of the HPV vaccine (received one or two shots)? Yes No
81 16) Have you ever engaged in oral sex or sexual intercourse? Yes No 17) Within the last three months, have you engaged in oral sex or sexual intercourse? Yes No 18) How knowledgeable do you feel about HPV? Very knowledgeable Knowledgeable Some knowledge Little knowledge No knowledge 19) How confident do you feel in your ability to protect yourself against HPV? Very confident Confident Moderately confident Little confidence No confidence 20) Human Papillomavirus (HPV) is the most common sexually transmitted disease. True False 21) HPV is linked to genital warts and cervical caner. True False 22) Ideally, women should be given the HPV va ccine before they become sexually active. True False 23) Have you heard of the HPV vaccine Gardasil? Yes No 24) Did you know that Gardasil is the only FDA-approved HPV vaccine available in the U.S.? Yes No
82 Next, youll be asked to rank your level of agreement with the following statements. 25) I am at risk of getting HPV. Strongly disagree Disagree Undecided Agree Strongly agree 26) Before Gardasil came on the ma rket, I knew nothing about HPV. Strongly disagree Disagree Undecided Agree Strongly agree 27) The HPV vaccine can help pr otect me against cervical cancer. Strongly disagree Disagree Undecided Agree Strongly agree 28) I am worried about getting HPV and/or cervical cancer. Strongly disagree Disagree Undecided Agree Strongly agree 29) I am afraid people will negatively judge me if I get the HPV vaccine. Strongly disagree Disagree Undecided Agree Strongly agree 30) The HPV vaccine is safe. Strongly disagree Disagree Undecided Agree Strongly agree
83 31) My partner (boyfriend/girlfriend/spouse) would not trust me if I got the HPV vaccine. Strongly disagree Disagree Undecided Agree Strongly agree 32) My family would be supportiv e of me getting the HPV vaccine Strongly disagree Disagree Undecided Agree Strongly agree 33) I believe that the information presented in the news media about the HPV vaccine is accurate. Strongly disagree Disagree Undecided Agree Strongly agree 34) I believe that the inform ation presented in advertis ements for the HPV vaccine Gardasil is accurate. Strongly disagree Disagree Undecided Agree Strongly agree 35) My overall impression of the HPV vaccine is: Very negative Negative Undecided Positive Very positive 36) I regularly seek out info rmation about health issues. Strongly disagree Disagree Undecided Agree Strongly agree
84 37) Information from the mainstream news media influences my health decisions. Strongly disagree Disagree Undecided Agree Strongly agree 38) Information presented in advertisemen ts influences my health decisions. Strongly disagree Disagree Undecided Agree Strongly agree Now, youll be asked how often you engage in each of the following behaviors. 39) How often have you talked with pe ople like you about the HPV vaccine? Never Rarely Occasionally Frequently Always 40) How often have you talked with your doctor or other health care provider about the HPV vaccine? Never Rarely Occasionally Frequently Always 41) How often have you talked with your family about the HPV vaccine? Never Rarely Occasionally Frequently Always 42) How often have you talked with your pa rtner (boyfriend/girlfriend/spouse) about the HPV vaccine? Never Rarely Occasionally Frequently Always
85 43) How do you feel about vaccines in general? 44) Please select one of the following: I want to get the HPV vaccine. (O r, I have already received it.) I do not want to get the HPV vaccine. ( If so, skip to question 46.) I am undecided on whether to get the HPV vaccine. ( If so, skip to question 47.) 45) Which factors most influe nced your decision in favor of getting the HPV vaccine? (Select all that apply.) (After this, skip to question 48.) I want to protect myself against HPV My doctor recommended it I believe the vaccine is effective My family said I should My insurance covers at least pa rt of the cost of the vaccine The news media portrayed the vaccine positively I fear that I am at risk for HPV and/or cervical cancer My friends said I should I believe the vaccine is safe My partner (boyfriend/girl friend/spouse) said I should I know someone who ha s/had cervical cancer The vaccine is easy to get Other: ____________________ 46) Which factors most influe nced your decision against getti ng the HPV vaccine? (Select all that apply.) (After this, skip to question 48.) I am not at risk for HPV The vaccine is too expensive I dont think the vaccine is effective My doctor said not to I dont know anything about the vaccine The vaccine has too many potential side effects My friends said not to Ive probably already been exposed to HPV, so its too late for me Im not worried about getti ng HPV and/or cervical cancer I dont think the vaccine is safe My family said not to I am against vaccinations in general The news media portrayed the vaccine negatively I think Im too old to get the vaccine The vaccine is difficult to get I believe that it is an unnecessary vaccine My partner (boyfriend/girlfriend/spouse) said not to Other: ____________________
86 47) Which factors are most lik ely to influence your eventual decision regarding the HPV vaccine? (Select all that apply.) My personal risk of getti ng HPV and/or cervical cancer The cost of the vaccine The availability of the vaccine My feelings about vaccines in general The recommendations of my doctor My level of concern about get ting HPV and/or cervical cancer Information about the vaccine presented by the news media The opinions of my friends The safety of the vaccine The opinions of my family The effectiveness of the vaccine My age My friends or family members experience with cervical cancer The opinion of my partner (boyfriend/girlfriend/spouse) Other: ____________________ Lastly, youll be asked how you get health-related information. 48) When I have a question about a he alth issue, I am most likely to: Ask my doctor Look it up using an Internet search engine, like Google Go to a library Ask a friend Look it up in an online newspaper or magazine Ask a family member Look it up on the Web site of an official me dical organization, like the Centers for Disease Control and Prevention Ask my partner (boyfri end/girlfriend/spouse) Other: ____________________ 49) The majority of my information about HPV has come from: (Select all that apply.) Peers Mainstream news media, including online sources My doctor Advertisements Family members Official medical organizati ons, like the Centers for Disease Control and Prevention My partner (boyfriend/girlfriend/spouse) Blogs Other Web sites None of these Other: ____________________
87 50) The majority of my information about the HPV vaccine has come from: (Select all that apply.) My doctor Advertisements Peers Mainstream news media, including online sources Family members Official medical organizations, like the Centers for Disease Control and Prevention My partner (boyfriend/girlfriend/spouse) Blogs Other Web sites None of these Other: ____________________ 51) What type of mass media has provided you with the most information about the HPV vaccine ? (Select all that apply.) Newspapers (online or print) Magazines (online or print) Television Radio Blogs Other Web sites Advertisements None of these Other: ____________________ 52) Where have you seen advertisements for the HPV vaccine Gardasil? (Select all that apply.) On television In magazines In newspapers In my doctors office Online At the student health clinic Nowhere Other: ____________________
88 53) Of the following media sources, which has most influenced your decision about whether to get the HPV vaccine ? (Select all that apply.) News articles (in newspapers or ma gazines, either online or in print) Opinion pieces (like letters to the editor or columns, either online or in print) Television news programs (like Anders on Cooper 360 or Good Morning America) Television commentary programs (like Countdow n with Keith Olbermann or The OReilly Factor) Television entertainment pr ograms (like Greys Anatomy) Radio news programs (like Evening Edition on NPR) Radio commentary programs (lik e The Rush Limbaugh Show) Advertisements for Gardasil (in print, on television, or online) Blogs Other Web sites None of these Other: ____________________ 54) How often do you use the following type s of media for information about the HPV vaccine ? a) Newspapers (online or print) Never Rarely Occasionally Frequently Always b) Magazines (online or print) Never Rarely Occasionally Frequently Always c) Local television stations, like Ga inesville TV 20 or Orlando WESH Never Rarely Occasionally Frequently Always d) National network television statio ns, like ABC, CBS, CNN, Fox, and NBC Never Rarely Occasionally Frequently Always
89 e) Blogs Never Rarely Occasionally Frequently Always f) Web sites of official medical organizations Never Rarely Occasionally Frequently Always 55) How often do you use the following types of media for information about health issues in general ? a) Newspapers (online or print) Never Rarely Occasionally Frequently Always b) Magazines (online or print) Never Rarely Occasionally Frequently Always c) Local television stations, like Ga inesville TV 20 or Orlando WESH Never Rarely Occasionally Frequently Always d) National network television statio ns, like ABC, CBS, CNN, Fox, and NBC Never Rarely Occasionally Frequently Always
90 e) Blogs Never Rarely Occasionally Frequently Always f) Web sites of official medical organizations Never Rarely Occasionally Frequently Always Thank you for your participation! For more information about the HPV va ccine, visit the fo llowing Web site: http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine-young-women.htm
91 APPENDIX B CONSTRUCTION OF VARIABLES USED IN REGRESSION ANALYSIS Dependent Variable Vaccination status and desire Percent Has received HPV vaccine 37% (41) Wants to get HPV vaccine 23% (26) Undecided on whether to get HPV vaccine 30% (33) Does not want to get HPV vaccine 10% (11) (mean = 1.49; sd = .672) Independent Variables Race/ethnicity Percent White 64% (72) Not white 36% (40) (mean = .64; sd = .48) Annual income Percent Less than $25,000 43% (48) More than $25,000 57% (64) (mean = .57; sd = .50) Social ideology Percent Liberal 51% (57) Neutral or conservative 49% (55) (mean = .51; sd = .50) Religiosity Percent Religious 49% (55) Not religious 51% (57) (mean = .50; sd = .50) Sexual experience Percent Has engaged in oral sex or sexual intercourse 84% (93) Has not engaged in oral sex or sexual intercourse 16% (19) (mean = .84; sd = .37)
92 Media use frequency for HPV vaccine information index How often do you use the following types of media for information about the HPV vaccine? Never Rarely Occasionally Frequently Always Newspapers (online or print) 42% (47)32% (36)22% (24)2% (2) 2% (2) Magazines (online or print) 28% ( 30)29% (32)31% (34)10% (11) 2% (2) Local TV stations 38% (42)27% (30)24% (26)7% (8) 4% (4) National TV stations 22% (24)27% (30)33% (36)15% (16) 3% (3) Blogs 57% (62)25% (27)13% (14)3% (3) 2% (2) Web sites of official medical organizations 26% (29)16% (18)31% (34)19% (21) 8% (9) (Cronbachs alpha = .81; mean = 13.13; sd = 4.66) Media use frequency for health information index How often do you use the following types of media for information about health issues in general? Never Rarely OccasionallyFrequently Always Newspapers (online or print) 24% ( 27)23% (25)26% (29)24% (26) 3% (3) Magazines (online or print) 22% (24)17% (19)30% (33)25% (28) 6% (6) Local TV stations 29% (32)32% (35)23% (25)15% (16) 1% (1) National TV stations 16% (17)20% (22)35% (38)28% (30) 1% (1) Blogs 48% (53)21% (23)17% (19)12% (13) 2% (2) Web sites of official medical organization 7% (7)15% (16)28% (31)32% (35) 18% (20) (Cronbachs alpha = .95; mean = 15.72; sd = 4.63)
93 Perceived knowledge an d self-confidence index Perceived knowledge about HPV Percent Very knowledgeable 10% (11) Knowledgeable 24% (27) Some knowledge 38% (43) Little knowledge 23% (26) No knowledge 5% (5) Confidence in ability to pr otect ones self against HPV Very confident 25% (28) Confident 38% (42) Moderately confident 30% (34) Little confidence 5% (6) No confidence 2% (2) (r = .34; mean = 5.10; sd = 1.61) Interpersonal sources index How often have you talked with the following people about the HPV vaccine? Never Rarely Occasionally Frequently Always Peers 15% (17)35% (39)41% (46)8% (9) 1% (1) Doctor or other health care provider 31% (35)20% (22)37% (42)11% (12) 1% (1) Family members 23% (26)27% (30)40% (45)10% (11) 0% (0) (Cronbachs alpha = .84; mean = 7.12; sd = 2.44) Trust of HPV vaccine safety and information index Please rate your level of agreement with the following statements. Strongly Disagree DisagreeUndecided Agree Strongly Agree The HPV vaccine is safe. 1% (1)3 % (3)35% (40)45% (50) 16% (18) I believe that the information presented in the news media about the HPV vaccine is accurate. 0% (0)3% (3)43% (48)44% (49) 10% (11) I believe that the information presented in advertisements for the HPV vaccine Gardasil is accurate. 0% (0)3% (3)29% (32)55% (61) 13% (14) (Cronbachs alpha = .76; mean = 11.15; sd = 1.81)
94 Peer judgment index Please rate your level of agreement with the following statements. Strongly Disagree Disagree Undecided Agree Strongly Agree I am afraid people will judge me negatively if I get the HPV vaccine. 58% (65)23% (26)7% (8)9% (10) 3% (3) My partner (boyfriend/girlfriend/spouse) will not trust me if I get the HPV vaccine. 58% (65)30% (34)8% (9)2% (2) 2% (2) (r = .60; mean = 3.34; sd = 1.75) Family support Please rate your level of agreement with the following statement. Strongly Disagree Disagree UndecidedAgree Strongly Agree My family would be supportive of me getting the HPV vaccine. 3% (3)3% (3)17% (19)31% (35) 46% (52) (mean = 1.49; sd = .67)
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100 BIOGRAPHICAL SKETCH Sara J. Henneberger graduated in 2003 fr om Carnegie Mellon University, where she double majored in professional wr iting and ethics, history, and public policy. She then worked for three years in nonprofit communications, journalism, and social work in the San Francisco Bay Area before beginning her grad uate studies at the University of Florida in the fall of 2006. Sara completed concurrent masters degrees in mass communication and public health, along with a graduate certificate in womens studies. Her areas of concentration included journalism, social and behavioral sciences, and health management and policy. She will graduate with her MAMC (with distinction) and MPH in August 2009. For the last four years she has worked as the copy editor of the Globe an Oakland, California-based weekly newspaper. During the 2009 spring semester, she interned with the Florida Public Health Associations Sexually Transmitted Disease Section. There she completed a health indicators report and be st practices report focusing on sexual and reproductive h ealth in Florida. The results of this project were presented during the 2009 Florida Public H ealth Association and Southern Health Associat ion Joint Annual Educational Conference.