Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

Why Public Health’s Current Approach to HPV is Failing - Lucia Egbert

The New York Times’ recent report that almost 20% of American teenage girls have human papilloma virus (HPV) begs the question: What is public health doing to effectively address this prevalent sexually transmitted disease (1) ? The public debate around HPV began when Gardasil, the vaccine produced by Merck that immunizes against four of the strains that cause cervical cancer and genital warts, was released in 2006. The discourse escalated when at least 20 states attempted to mandate the vaccine for pre-pubescent girls. Amongst public health and medical professionals, the answer to the vaccine mandate remains unclear (7,9,12).

In this paper, I critique public health’s approach to the HPV epidemic using three frameworks from the social and behavioral sciences. My first argument explains how stigma against sexually transmitted diseases (STDs), like HPV, is a barrier that public health needs to address in order to effectively combat HPV. Second, I argue that the possibility of mandated vaccinations weakened public health’s campaign against HPV because many parents perceived it as coercive. My final argument uses an eco-epidemiological framework to suggest that public health’s current approach is inadequately addressing the complexities of the HPV disease and epidemic.

Background and Literature Review

The literature on HPV mostly discusses the HPV vaccine and the epidemiology of the disease. After the Federal Drug Administration approved Gardasil, both academic journal and newspaper articles spelled out the public health controversy over the vaccine (7,12). Still, there is little public knowledge or understanding about how HPV is transmitted and how it causes cervical cancer (20).

Before addressing the failings of public health’s approach to HPV, I will review some of the relevant individual and population level approaches to creating behavioral change. A more comprehensive look at individual versus population level behavioral interventions can be found in Manhart and Holmes’ 2005 article (8), Randomized Controlled Trials of Individual-Level, Population-Level, and Multilevel Interventions for Preventing Sexually Transmitted Infections: What Has Worked?

Behavioral Change at the Individual Level

The key model for individual behavioral change is the classic Health Belief Model. In this model, if an individual believes that the benefits of changing their personal behavior outweigh the costs and barriers to taking action, then they will change their behavior. The “benefits” are based on avoiding what an individual perceives as their susceptibility to the disease and the severity of the disease’s consequences (10). Other individual level models are similar to the Health Belief Model because they share the paradigm that individuals’ perceptions of the consequences of not changing, ie. developing a disease, and other factors that influence their behaviors, form their intentions to change, which results in behavioral change. The Self-Efficacy Model says that if individuals perceive adequate self-efficacy in their situation, they will be able to change their behavior. The Social Norms Model says that individuals are rational beings that act according to what they perceive as good or bad. These perceptions are influenced by our judgments that are based on social pressures and norms (11).

Public health campaigns are traditionally based on these individual level models of behavioral change. This is one of the reasons that public health has failed to adequately address the HPV epidemic. In my critique, I do not use individual level models of behavioral change, but they are important to keep in mind in contrast to the population level models.

Behavioral Change at the Population Level

The Normative-Re-educative model for changing behavior recognizes that people’s behaviors reflect social intelligence and cultural norms. This is because norms affect our individual habits and values. Therefore, the model says that in order to make change we must involve individuals in the process of changing social norms, thereby re-educating themselves and society as a whole (2).

In contrast to the Normative-Re-educative strategy, strategies like the Power-Coercive model use economic and political force to change population behavior. Coercive measures to change population behaviors are common in our political system; for instance, mandates of vaccinations for all school-aged children are coercive. People are often oblivious to the impact of coercive laws because often they tend to be to our benefit. However, when a difference of opinion arises on a mandated vaccine like Gardasil, the population may divide on their acceptance of such a vaccine based on individuals’ opinion (2).

One interesting hypothesis on behavioral change addresses the media’s influence on attitude and behavior. One social and behavioral sciences study looked at how the media impacts adolescent sexual behavior. The study reviewed the literature on media influences, and found that youth and adolescents have a wide exposure to media including television, videos, movies, video games, computer and internet. The sexual content in these media has increased in the past two decades. This increase may have impacted the rise in sexual activity amongst youth and changes in their attitudes and decision-making during that time period (5).

A key restraint to public health’s ability to effect behavioral change is that epidemiological research is often guided by individual risk factors (16) rather than causes for disease within populations (14). Because of this approach, the systemic reasons for ubiquitous diseases like homelessness may be overlooked (14). A recent approach to epidemiology called Eco-epidemiology recognizes that diseases need to be approached on multiple levels, from the biomedical level to the population level, and that these levels interrelate (17). This approach allows epidemiologists to deal with the complexities of disease and to address the biological and deep sociological causes at the same time.

Three Social Sciences Arguments for Why the Public Health Approach to HPV is Failing

Public health has failed to develop an approach or a campaign to unite public health professionals, medical professionals, and the public, to best utilize the vaccine. The social and behavioral sciences can help us to see the weaknesses in the current approach. One weakness is that the vaccination campaign and even the behavioral health campaign, which are mainly communicated through medical providers, focus on individual behavioral change. This approach is clearly a mistake because HPV is so widespread. It is a social problem that should be addressed on a social or group level. Instead or recognizing this, public health has once again used the health belief model for behavioral change. They assume that informing the public about their susceptibility to the disease will make them want to change their behaviors, i.e. getting a vaccine and stopping participation in risky sexual behavior. In this section, I will use three population-level models of behavioral change to explain why public health’s approach is failing.

Argument 1: Public Health has Failed to Address Stigma Around HPV

The first barrier that public health has failed to address that would change the scene for fighting HPV is the stigma attached to STDs and to adolescent and premarital sex (6). The current nationally promoted approach to sex education is abstinence-only until marriage (19). This stance both reflects and perpetuates stigma against adolescents who are sexually active.

The consequence of stigmatizing sexually active adolescents is that stigma creates an unnecessary barrier to adolescents seeking information about HPV. Because adolescents may be afraid of their parents or friends finding out that they are sexually active, they may be less likely to get tested or treatment. Stigma against HPV may also affect condom use amongst adolescents (13).

Stigma against premarital sex and societal fears around promiscuity has closed the public discourse on sexual activity for adolescents. As a result, parents might not know that their children are at risk from contracting HPV from other sexual activities besides penetrative intercourse. Stigma against adolescent sexual activity therefore discourages parents from vaccinating their daughters when the vaccine is most effective, when they are young and prior to beginning sexual activity (12).

Argument 2: The HPV Vaccine Mandate is Perceived as Coercive

The second barrier to combating HPV is the failure of public health’s attempt to mandate the vaccine nationally and at the state level. One argument is that the attempted mandates were mistimed or misguided (12). Because the public was not convinced of the efficacy of and need for the vaccine, when the possibility of a mandated vaccine arose, there was a public outcry (7). The campaign to promote state mandates of the vaccine ended up backfiring against public health and has ended up hurting the movement against HPV because parents perceived the mandate to be coercive (7).

Because the vaccine mandate backfired, some parents may feel like they are left hanging as to what to do to protect their children against HPV. Public health has failed parents and children by not developing a clear and empowering solution to preventing HPV since the vaccine mandates were rescinded. Public health professionals should use Framing Theory in order to steer the discussion away from the issues that instill fear and highlight stigma. Instead, they should refocus their attention on the benefits of comprehensive sexual healthcare.

Argument 3: The Public Health Approach to HPV is Not Comprehensive

The third barrier is that the current public health approach is unfocused and lacks agreement. Part of the current approach consists of a weak campaign to vaccinate all girls. Many public health professionals and parents perceive this aspect of the campaign as being driven by Merck’s financial goals (12, 20). Another driving force of the current approach to HPV is the biomedical model. Because so many questions remain about the etiology of HPV and the efficacy of the vaccine, many public health and medical professionals alike are unclear as to the best approach to combating HPV (12). The prevalence of HPV is so high (the CDC’s conservative estimate is that over 50% of men and women in the US will contract HPV at some point in their lives) (3) that its causes need to be studied at a population level. Using an Eco-epidemiological lens to addressing the disease would allow public health professionals to adequately address the multi-level and complex nature of HPV as a disease and an epidemic.


What is most apparent about the campaign against HPV is that it lacks comprehensiveness. Because it largely relies on the biomedical approach, it fails to recognize that the problem is multi-level. That is, HPV must be addressed at the microbiological level, at the prevention and medical level, and at the societal level. A comprehensive and cohesive campaign would be most appropriate for addressing the HPV epidemic.

My recommendation for public health’s campaign against HPV is to address these weaknesses by exploring population-level approaches to behavioral change. To change stigma against the disease and also to avoid coercive measures, public health should consider using a Normative-Re-educative or persuasive approach. They should also move from the medical model, which currently leaves too many questions, to an Eco-epidemiological approach, which entails a more comprehensive view of the disease.

In order to develop a better strategy for changing social attitudes toward STDs like HPV, it has been recommended to perform formative research within the affected populations to understand the deeper reasons behind these epidemics (15).


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