Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008

One Less or One More? A Social and Behavioral Sciences Critique of Merck’s “One Less” Campaign— Stephanie Kim

According to the Centers for Disease Control and Prevention (CDC), approximately 20 million people are currently infected with the human papillomavirus (HPV), with about 6.2 million Americans acquiring new genital HPV infections each year. What is even more alarming is the CDC’s estimate that by age 50, at least 80 percent of women will have acquired a genital HPV infection (1). In 2006, Merck & Co., Inc. launched its nationwide campaign promoting Gardasil, a vaccine that offers protection from certain types of HPV, including those that are associated with cervical cancer. The $40 million campaign is called “One Less”, in reference to the vaccine’s promise to make a woman ‘one less’ affected by cervical cancer. Though Gardasil is heralded by some as “the world’s first and only cancer vaccine”, Merck’s “One Less” campaign fails to provide adequate information about HPV, disregards socioeconomic disparities in the general public, and supports coercion tactics that promote a false sense of security. Until these factors are fully addressed, these shortcomings will severely limit the campaign’s effectiveness and result in detrimental outcomes that may, in fact, contribute to ‘one more’ woman being affected by cervical cancer.

Implications of the Framing Theory
Gardasil is a vaccine that may help guard against HPV Types 6, 11, 16, and 18. HPV Types 16 and 18 cause 70 percent of cervical cancer cases, while HPV Types 6 and 11 cause 90 percent of genital warts cases (2). Currently, the “One Less” campaign markets Gardasil as a “Cervical Cancer Vaccine”, emphasizing the link between HPV and cervical cancer. While the “One Less” campaign debuted in 2006, it was preceded by Merck’s “Tell Someone” and “Make the Connection” campaigns, which also focused on generating awareness of the connection between HPV and cervical cancer (3). These campaigns were used to prime the U.S. market for the upcoming release of Gardasil, which was still pending approval from the Food and Drug Administration at that time. A major flaw in all three campaigns is the absence of a vital piece of information about HPV— that HPV is a sexually transmitted disease (STD) (1).

Through campaigns like “One Less” and its predecessors, Merck consciously chose to frame HPV in reference to cervical cancer, not as an STD. Undoubtedly, the link between HPV and cervical cancer is significant. According to the National Cancer Institute (NCI), HPVs are now recognized as the major cause of cervical cancer (4). Thus, this issue is not a matter of facts or what is right or wrong; rather, it is a matter of framing. The key missing component in Merck’s definition of HPV is that HPV is an STD, primarily transmitted through genital contact (1). In fact, HPV is presently the most common STD in the United States (1). Still, Gardasil’s website, print advertisements, and 59-second television commercial all fail to mention that HPV is an STD. Whether this omission is intended to invoke fear in individuals or to avoid the subject of sex, it will likely result in detrimental consequences due to the target population’s ignorance about the transmission of HPV.

The Framing Theory relates to how an individual thinks about an issue. When conveying information to the public, the way in which an issue is framed has important implications, often long-lasting, for individuals’ opinions and attitudes (5). In the case of the “One Less” campaign, an individual’s perception of HPV is significantly altered because it is portrayed only in reference to cervical cancer and not as an STD. This framing can lead the individual to think that HPV is not an STD, since it is not mentioned in the advertisements. The advertisements only address downstream effects, such as the causal factors related to HPV, and neglect to mention upstream effects, like the causes of HPV. In other words, they do not answer the question “What causes HPV?” and instead focus on the most proximal factor associated with HPV: cervical cancer. NCI’s 2005 Health Information National Trends Survey (HINTS) found that only 40 percent of those surveyed had ever heard about HPV and of that, only 64 percent of those surveyed knew that HPV could be sexually transmitted (6). The lack of information about the transmission of HPV in Merck’s advertisements will not improve these statistics but will instead promote behaviors that may increase HPV and cervical cancer. In fact, the results of a 2004 study by Bernard, et al. found that the college students under observation showed a correlation between having fairly low HPV- knowledge levels and participating in high-risk sexual behaviors for HPV infection, including the failure to get Pap smears(7). Thus, it is probable that the failure to provide the public with adequate information about HPV will propagate ignorance about the transmission and progression of HPV and as a consequence, fuel the spread of HPV and cervical cancer, rather than help to prevent it.

Limitations of the Health Belief Model
The Health Belief Model is based on the assumption that intention should lead directly to behavior (8). Applying this model to the “One Less” campaign would result in the following: If the advertisements lead an individual to determine that the benefits of receiving the vaccine (protection against cervical cancer) outweigh the costs (side effects from the vaccine, including fever, dizziness, and nausea), the Health Belief Model states that the individual’s intention (to obtain the vaccine) will lead to that behavior (of obtaining the vaccine). In reality, many who intend to receive the vaccine ultimately do not: according to a 2006 Annenberg National Health Communication Survey, 42 percent of respondents had heard about a vaccine for HPV, but 80 percent of those indicated never having talked to a health care provider about the virus (6). This discrepancy can be attributed to the fact that the “One Less” campaign utilizes the Health Belief Model, but neglects to consider the limitations of the model. More specifically, the campaign does not recognize that intention is not an accurate reflection of an individual’s actual behavior (9) because factors such as socioeconomic disparities, including income and education level, are not taken into account.

While many private health plans provide coverage for Gardasil, at about $120/shot, the total cost of Gardasil (a 3-shot series) is approximately $360, plus the cost of office visits (2). The price for the vaccine is relatively steep, especially for the uninsured, so even if an individual’s intention is to receive the vaccine, she may not be able to afford it. Therefore, in this case, intention does not directly lead to behavior. Also, as previously mentioned, Gardasil is a 3-shot regimen that spans 6 months. Uninsured children in the target age group (ages 9-26) may not be able to afford to visit physicians that frequently, which may also prevent intention from leading directly to behavior (10).

Additionally, Merck’s advertisements for Gardasil span various television networks, the internet, and print media outlets, including magazines such as “Women’s Health” and posters in doctor’s offices. These types of media only reach a certain subset of the population, excluding those without access to televisions, computers, the internet, magazines, as well as those who are illiterate. By failing to reach this sector of the population, Merck essentially ignores those who are at a greater risk of being afflicted with HPV. A recent study by the National Health and Nutrition Examination Survey (NHANES) provided the first national estimate of the prevalence of HPV infection among women in the United States aged 14 to 59. Investigators found that a total of 26.8 percent of women overall tested positive for one or more strains of HPV and that the prevalence of HPV is higher in non-Hispanic black women with education levels below high school who live below the poverty level (11). Based on these demographics, it is likely that many of these women are uninsured and/or do not have access to a television, computers, the internet, and magazines such as “Women’s Health”. Additionally, many of these women may be illiterate, given their low education levels. Therefore, it is probable that these women cannot receive the vaccine, let alone obtain information about the vaccine, and any intention they may have of receiving the vaccine certainly will not lead to the behavior of vaccination. Since Merck fails to account for socioeconomic differences in the population when utilizing the Health Belief Model, they are excluding those most at risk of contracting HPV by preventing them from receiving the vaccine or any information about the vaccine.

Inappropriate Use of the Power-Coercive Approach
Since the CDC recommends Gardasil for girls and women ages 9 to 26 years (1), oftentimes, a girl’s parent must make the decision about whether or not his or her daughter should receive the vaccine. A power-coercive approach uses the force of law to try to change people’s behaviors (12). Recently, many state legislators in the United States have considered a power-coercive approach to encourage vaccination, by supporting bills to make Gardasil mandatory for girls entering schools (though most, if not all, have an “opt-out” policy) (13). The push for mandatory vaccination was an effort funded by Merck in the past (14). Traditionally, mandating vaccines has only been reserved for diseases that are easily spread and pose as a public health risk (15). However, HPV is not a communicable disease, since it is not spread through casual contact, but rather through intimate contact. Thus, it is questionable whether medical coercion, as carried out by the government, is appropriate because mandating Gardasil may inadvertently encourage a false sense of security and lead to a rise in promiscuous behavior in young girls.

Coupling a power-coercive approach with advertisements that frame HPV as a “cervical cancer vaccine” may prove to be detrimental, especially in light of a recent study by the CDC which found that at least one in four teenage girls nationwide has an STD, with HPV being the most prevalent (16). In essence, making Gardasil mandatory for girls may lead to a rise in behavioral disinhibition, which the CDC defines as "an increase in unsafe behaviors in response to perceptions of safety caused by introduction of a preventive or therapeutic intervention” (17). Simply put, mandating Gardasil may promote false confidence. It is likely to foster the belief that one will be immune to HPV and cervical cancer, when in reality, Gardasil only protects against 70 percent of the strains of the virus that cause cervical cancer. An article by Kahn, et al. states that if vaccine recipients believe they are protected from HPV and cervical cancer, they may engage in higher risk sexual behaviors and overlook routine gynecologic care (18). As a result, girls may be less inclined to get Pap smears and cervical screening. Pap smears and early cervical screening are crucial for HPV diagnosis, because most people who have a genital HPV infection do not know that they are infected, since the virus lives in the skin or mucous membranes and usually causes no symptoms (1). In fact, most women are diagnosed with HPV on the basis of abnormal Pap tests. Additionally, the American Cancer Society states that cancer of the cervix may be prevented or detected early by regular Pap tests; if it is detected early, cervical cancer is one of the most successfully treatable cancers (19). Conversely, failing to get Pap smears and cervical screening can lead to later detection of cervical cancer and a rise in cervical cancer fatalities.

Likewise, assuming that the recipients of the vaccine are aware that HPV is an STD, this vaccine may also spur the belief that it protects against all STDs, decreasing their perceived susceptibility for contracting not only HPV, but all STDs. According to an article by Zimet, et al., vaccine acceptance may be associated with subsequent changes in STD risk and protective behaviors. It is postulated that post-immunization, the vaccine may influence behaviors by decreasing perceived personal susceptibility to STDs (20). Additionally, 11 percent of the pediatricians at a 2005 Advisory Committee for Immunization Practices meeting said they thought vaccinating against a sexually transmitted disease “may encourage risky sexual behavior in adolescent patients” (21). This behavior is exemplified in a study by Webb, et al., where adolescents were asked how they thought teen-agers would behave after receiving a highly effective HIV vaccine: 77 percent believed that adolescents would substantially increase their engagement in risky sexual behavior (22). It follows that adolescent girls may mistakenly think that Gardasil is a universal safeguard against all STDs (23), increasing the likelihood that they will engage in unsafe sex. Unsafe sex practices will not only lead to a rise HPV, it will also lead to a rise in all other STDs, including HIV.

Furthermore, a government-issued mandate for Gardasil would deny parents the free will and authority to decide whether or not this vaccine is appropriate for their daughters. Like the pediatricians surveyed, some parents are apprehensive of the vaccine because of the concern that it may promote early initiation of sexual activity (24). Additionally, if parents take their daughters to receive Gardasil, a vaccine for an STD, girls may misinterpret this act as her parents essentially giving her consent to engage in sexual activity, undermining any messages of abstinence parents may have enforced beforehand (17). By promoting behavioral disinhibition, Merck and the government’s coercive approach to mandate Gardasil may cause more problems in the fight against HPV, STDs, and cervical cancer.

Gardasil’s “One Less” campaign falls short on many levels. Unless properly addressed, Merck’s failure to provide the public with the knowledge that HPV is an STD, neglect to account for socioeconomic disparities when utilizing the Health Belief Model, and support for mandating the vaccine through a power-coercive approach will contribute to the rise of HPVs, cervical cancers, and STDs.

1. Centers for Disease Control. Human Papillomavirus (HPV) Infection. Atlanta, GA: Centers for Disease Control.
2. Merck & Co., Inc. Gardasil. Whitehouse Station, NJ:
3. The Henry J. Kaiser Family Foundation. FDA Announces Approval of HPV Vaccine Gardasil. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 2006.
4. National Cancer Institute. Human Papillomaviruses and Cancer: Questions and Answers. Bethesda, MD: National Cancer Institute. cancertopics/factsheet/Risk/ HPV.
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6. American Association for Cancer Research. What Does the Public Really Know about HPV? Philadelphia, PA: American Association for Cancer Research.
7. Bernard, Amy, Cottrell, Randall, Ingledue, Kimberly. College women's knowledge, perceptions, and preventive behaviors regarding Human Papillomavirus infection and cervical cancer. American Journal of Health Studies 2004; 19: 1.
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13. Wilson, Brenda. “States consider requiring HPV vaccine for girls.” National Public Radio 5 February 2007.
14. Associated Press. Drugmaker stops lobbying efforts for STD shots.” MSNBC News 20 February 2007:
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16. Associated Press. Study: 1 in 4 teen girls has an STD. CNN 11 March 2008:
17. Gibbs, N. Defusing the war over the ‘promiscuity’ vaccine. Time Magazine 21 June 2006.
18. Kahn JA, Bernstein DI. Human papillomavirus vaccines. Pediatric Infectious Disease Journal 2003; 22: 443–35.
19. American Cancer Society. Cervical Cancer: Prevention and Early Detection. Atlanta, GA: _Cancer_Prevention_and_Early_Detection_8.asp?sitearea.
20. Zimet, GD, Mays R, Fortenberry JD. Vaccines against sexually transmitted infections: promise and problems of the magic bullets for prevention and control. Journal of the American Sexually Transmitted Diseases Association 2000: 27: 49-52.
21. Cervical cancer vaccine gets injected with a social issue. Washington Post 2005 October 31: A03.
22. Webb PM, Zimet GD, Fortenberry JD, et al. HIV immunization: acceptability and anticipated effects on sexual behavior among adolescents. Journal of Adolescent Health 1999; 25: 320-322.
23. Kapoor, S. The HPV vaccine and behavioral disinhibition. Journal of Adolescent Health 2007; 42: 105.
24. Olshen E, Woods ER, Austin SB, et al. Parental acceptance of the human papillomavirus vaccine. Journal of Adolescent Health 2005; 37: 248 –51.

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