https://orcid.org/0000-0002-7115-0001
ABSTRACT
To respond to potential public health impacts of social media influencing vaccine confidence, Facebook proposed that prior to proceeding to any link about Human Papillomavirus (HPV) vaccination, a pop-up will prompt the user to visit a reputable website on vaccine information. This study explored the acceptability of a pop-up Facebook message for HPV vaccine information. A national sample of U.S. adults (n = 579) was surveyed online. Most participants rated the pop-up messages as acceptable, useful, and factual. Regression results indicated that being male, seeing HPV content on social media in the past month, believing that information on social media is credible, holding positive HPV vaccination attitudes, and having shared HPV content on their own social media were associated with greater likelihood of clicking on a pop-up. While the pop-up approach may be acceptable, there are many factors that may be associated with being less likely to click on the pop-up.
Human Papillomavirus (HPV) vaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) to prevent several HPV-related cancers, such as cervical, anogenital, and oropharyngeal cancer.Citation1 Routine HPV vaccination is recommended for children 11–12 years, with eligibility as early as 9 years and catch-up vaccination available until age 26.Citation2 Recent ACIP recommendations have now included adults aged 27–45 with a shared clinical decision with their healthcare provider, based on emerging evidence of vaccine efficacy among this older age group.Citation3,Citation4 While HPV vaccination has been available for over a decade, just over half (54.2%) of adolescents are up-to-date on vaccination.Citation5
To support HPV vaccine uptake, it is important to provide accurate dissemination of vaccine information. One increasing form of vaccine information dissemination is social media, which is concerning given that a majority of vaccine content on social media consists of misinformation, concerns about side effects, conspiracy theories with pharmaceutical companies, or other threats on vaccine efficacy.Citation6–11 Specific to Facebook, the most commonly used social media platform (69% of all adults),Citation12 a review of public posts from 2006 to 2016 found 45% had a negative tone (i.e., disparaging messages about the HPV vaccine or discouraged the uptake), 29.7% had a positive tone (i.e., supportive messages about the HPV vaccine or encourages the uptake), and 25.3% had a neutral tone, and negative tones increased over time.Citation11 The potentially negative role of social media on vaccine confidence led to a panel of HPV vaccination researchers identifying “increasing HPV vaccine confidence by intervening on social media” as a top research priority for HPV vaccination.Citation13
To combat the negative and misinformed content on their platform, Facebook proposed the use of pop-ups as a cue to action to learn more about vaccination prior to accessing a vaccine-related group or story. This pop-up would direct the user to more information from a reputable source, such as the World Health Organization. Although pop-ups to reduce misinformation were introduced during the COVID-19 pandemicCitation14 and developed for general vaccine misinformation,Citation15 the acceptability of these pop-ups specifically for HPV vaccination remains unknown. Given the plethora of negative information and misinformation related to HPV vaccination on social media platforms, including Facebook, it is critical to establish whether this type of proposed pop-up is acceptable for Facebook users to inform successful implementation and HPV vaccine promotion. Thus, the purpose of this brief report is to explore the acceptability of a pop-up message on social media for HPV vaccine information and determine factors that may make individuals more or less likely to click on a pop-up if it were to be implemented for HPV vaccination.
A cross-sectional study was conducted among adults 27–45 years of age with no history of HPV vaccination. Participants were recruited within the United States using Qualtrics online research panel, which is derived from an opt-in market research panel and social media. Qualtrics randomly selects potential respondents from the panel that may meet eligibility criteria, provides them with a link and broad overview of the survey, and then provides compensation to their research participants after survey completion. Oversampling, or recruiting additional participants from particular sub-groups, was performed for non-Hispanic Black and Hispanic groups due to higher HPV-related disparities among those populations (i.e., higher incidence rate of cervical cancer for Black and Hispanic women compared to White women; higher incidence rate of anal cancer for Black men compared to White men)Citation16,Citation17 so that we had adequate representation from participants with these backgrounds in our sample. Question 3 of the survey asked about HPV vaccination status. If a person stated they were previously vaccinated for HPV, the survey was ended. Only unvaccinated persons were included in the sample (n = 706). We subset our study sample to participants that indicated they had used Facebook in the past month (n = 579). Participant recruitment was performed between April and May 2020 and the study was approved by the North Texas Regional Institutional Review Board.
The primary outcome of interest was the likelihood of clicking on a pop-up about HPV vaccination on social media that would direct participants to a government website. A picture was shown to participants as an example for the pop-up. The figure resembled a mock-up based on a news story presenting the concept of pop-ups.Citation15 Essentially, the pop-up stated if the person wanted to learn about reliable and current information about HPV vaccination, to click on the World Health Organization website or continue to the post anyways. Participants were asked, “If you saw this type of pop-up on HPV vaccination, how likely is it that you would click on the link contained in that pop-up?” The five response options, based on 5-item Likert scale, ranged from “very unlikely” to “very likely.” The outcome was dichotomized to “likely to click” and “not likely to click” based on the distribution of the data and small cell sizes for a 5-category variable.
Attitudes regarding HPV vaccine pop-up were assessed by asking, “This type of pop-up would be:” Sub-items included “acceptable,” “useful,” “unwanted,” “factual,” and “annoying.” Based on the 5-item Likert scale, the response options ranged from “strongly agree” to “strongly disagree.” To assess the level of exposure to HPV vaccine information on Facebook, participants were asked, “How often do you see information about HPV vaccination on Facebook?” The response options included “several times a day,” “once a day,” “every other week,” “weekly,” “monthly,” “less than monthly,” and “never.” Perceived credibility was assessed by asking, “Please rate how much you agree with … HPV vaccine information I see on social media is credible; Information I see on social media makes me question the HPV vaccine,” with response options on a 5-point Likert scale. To measure the polarization of social media content, participants were asked, “The HPV vaccine content that I see on social media is …,” with response options including “primarily in favor of vaccination,” “primarily against vaccination,” and “a combination of in favor and against vaccination.” Participants were also asked if they had shared HPV vaccination content on their social media in the past 12 months (yes/no).
Demographic covariates included, sex assigned on birth certificate (male, female), race (White, Black, Other, Multiracial), ethnicity (Hispanic, non-Hispanic), educational status (high school or less, some college, college, graduate degree), age in years, and awareness of HPV (heard of HPV; yes/no).
SAS version 9.4 was used for all analyses. Descriptive statistics were estimated for all variables. Based on the distribution of the outcome variable (intent to click on pop-up), it was operationalized as a binary variable. For the multivariable model, we estimated unadjusted logistic regression models for all independent variables and the outcome variable. Variables that were statistically significant (p< .05) were retained in the final adjusted model. Adjusted odds ratios and 95% confidence intervals are reported. Finally, we conducted t-tests to compare the means for attitude measures by outcome group.
Participant demographics are summarized in . depicts participants’ attitudes about the HPV vaccine pop-up. For negative attitudes, 39.5% of participants agreed the pop-up would be annoying, and 32.7% agreed the pop-up was unwanted. As for positive attitudes, 49.8% reported the pop-up would be factual, 64.8% as useful, and 62.3% as acceptable. In addition, 29% of participants reported that they would strongly agree with the pop-up providing useful information, and 30.7% reported they strongly agreed that the pop-up would be acceptable. Only 18.7% of participants stated they believed the pop-up would be factual. Overall, participants who reported they would click on the pop-up had significantly more positive attitudes about the pop-up compared to persons reporting they would not click on the pop-up ().
Table 1. Sample demographics and modeling odds of intention to click on pop-up for HPV vaccination information (n = 579)
Table 2. Pop-up attitudes by likelihood of clicking on the pop-up
Figure 1. Attitudes about HPV vaccine pop-up.
Based on the unadjusted models, sex, educational attainment, exposure to information on Facebook, perceived credibility of information on social media, HPV vaccine attitude, polarity of HPV vaccine content on social media, and sharing of HPV vaccine information on social media were significantly associated with likelihood of clicking on the vaccination pop-up on social media ().
Based on the adjusted logistic regression model, males had 1.77 times higher odds (95% CI: 1.12, 2.79) than females of clicking on the pop-up. Participants who had no exposure to HPV vaccination information online had 59% lower odds (aOR: 0.41 (95% CI: 0.22, 0.76)) of clicking on the pop-up compared to those participants who had monthly exposure to such information. The more participants agreed to the statement “HPV vaccine information I see on social media is credible” the higher the odds they were willing to click the pop-up (aOR: 1.77 (95% CI: 1.32, 2.38)). Furthermore, participants who reported better attitudes and positive HPV content on social media had higher odds of clicking the pop-up (aOR: 1.21 (95% CI: 1.14, 1.28), aOR: 1.89 (95% CI: 1.14, 3.15), respectively). Participants who previously shared HPV vaccine content online had 2.50 times higher odds (95% CI: 1.12, 5.60) of clicking on the pop-up than those who had not.
This study examined the acceptability of pop-up messages on Facebook for HPV vaccine information among U.S. adults. Approximately half of the participants reported they would be likely to click on a pop-up if shown on social media to see evidence-based information on the vaccine. Specifically, persons who were more likely to click found the pop-up acceptable, useful, and factual.
While there was overall acceptability of this social media information strategy, the persons who were more inclined to click on a pop-up already had more favorable views on HPV vaccination, including positive attitudes about HPV vaccination, the belief that the information they see on social media is credible, and had previously shared HPV content online. In contrast, the people who do not see a lot of information on HPV vaccination online are less likely to engage with this pop-up strategy. Thus, this type of strategy may only really engage persons on the positive end of the spectrum with regard to HPV vaccination. Future research is needed to understand how to engage more hesitant groups as this is likely the target audience of these pop-up messages. Moving forward, we need to test if this type of strategy can change cognitions and behaviors for HPV vaccination, and other emerging health issues, such as COVID-19 vaccination.Citation18 Future research should also examine how exposure to pop-ups on HPV vaccination influences parental beliefs and behaviors to have their adolescents vaccinated for HPV given 11–12-year olds are the recommended age group for HPV vaccination.
Additionally, men were more likely than women in this sample to click on a pop-up for more HPV vaccine information. Previous research from national samples suggests that adult women are more likely to be aware of HPV and HPV vaccination compared to men.Citation19,Citation20 Given this disparity in awareness, men may have perceived more information needs with regard to HPV vaccination in this age group and thus reported being more likely to click on a pop-up compared to women, who may not have needed additional information.
These findings should be considered in the context of limitations, including that the sample was limited to 27–45-year old unvaccinated adults since these data are from a broader study focused on mid-adult vaccination rather than 18 years and older. The data collection via an online panel may also introduce selection bias as some segments of the population may have more access to online surveys or may be more likely to utilize online surveys as a form of additional compensation. Furthermore, data were collected during the initial phase of the COVID-19 pandemic and lockdowns, which may have also introduced some selection bias. However, we cannot speak directly to the exact impact the timing of this survey may have had on study outcomes. Finally, the visual of a vaccination pop-up on social media was hypothetical and not yet implemented for HPV vaccination or COVID-19 at the time of data collection; however, during the pandemic, similar pop-ups have been used for COVID-19 information. Thus, we cannot determine whether similar levels of acceptability and likelihood of clicking on a pop-up would exist in a real-world implementation strategy.
As the social media landscape continues to change for the spread of health information, understanding how to disseminate evidence-based information is needed. This study is a first step to understanding the acceptability of pop-ups on social media for HPV vaccination as efforts are still underway to address misinformation online.
Disclosure statement
Erika Thompson is a consultant for Merck on HPV vaccination. It is not related to the work presented here. No potential conflict of interest was reported by the other author(s).
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References
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