Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Why Drug Companies Should Not Be Responsible for Increasing Public Health Awareness: The Story of Gardasil – Katie Sklarsky

Genital Human Pappilomavirus (HPV) is the most commonly transmitted STD (1) effecting at least 50% of sexually active men and women at some point in their lives (2). There are 40 strains of HPV and most do not cause any symptoms. However, some low-risk types can lead to genital warts while some high-risk types can lead to cervical cancer (1). The American Cancer Society predicts that in 2008 over 11,000 women will be diagnosed with cervical cancer. Twenty percent of cervical cancers are not diagnosed until after the age of 65 while most diagnoses occur in midlife and rarely occur before the age of 20 (3). As most cervical cancers are caused by HPV, a disease that the majority of sexually active people will have at some point in their lives, it puts many women at risk for the disease relatively early on in their lives as compared to when they will be diagnosed with cervical cancer. Thus, in order to decrease the occurrence of cervical cancer it is important to try to decrease the prevalence of HPV as well as educate women on getting routine pap smears in order to catch cancers caused by HPV at the pre-cancerous stage (3).

Research conducted by Merck prior to FDA approval of their vaccination in 2006 showed that only 20% of women knew what HPV was. This caused Merck to launch a large advertising campaign to improve public awareness of HPV (4). Bev Lybrand, VP of the HPV franchise division at Merck claimed that, "The full public health benefit of reducing the burden of cervical cancer and HPV disease may be achieved through broad public awareness and vaccination with GARDASIL, which is the driving force behind One Less" (5), their advertising campaign. Despite their efforts to spread knowledge about HPV through their advertising campaigns, more recent research on HPV awareness shows that awareness is still low (6,7) and even when awareness is greater the number of women who have received the vaccination is still low (8).

If Merck’s intent to increase public awareness is to be met, their advertisements should be developed in a manner that reaches all of the populations at risk for HPV and eligible for Gardasil. According to the CDC, the vaccine is should be given to all 11 and 12 year old girls, while catch-up vaccinations are recommended for females aged 13-26. In some cases the vaccination is also recommended for 9 and 10 year olds (9). There are three populations that should be focused on: adolescent girls, teenage girls, and young adult females. Due to the fact that most girls under the age of 18 do not have the power to make their own medical decisions, parental education and awareness about HPV and Gardasil is necessary as well.

Upon evaluation of Merck’s advertising campaign it will be evident that Merck failed to reach key groups in their target populations. They failed to use social marketing theory leading to their advertisements only targeting one segment of their population of interest; their use of framing failed to speak to young adults and teenage girls; and, Merck’s attempt to make Gardasil a mandatory vaccination led to stigmatization of the vaccine thereby alienating the one population their advertising campaigns were tailored toward.

Failure to Use Social Marketing Theory

The Gardasil commercials have addressed the three different populations, adolescents/pre-teens, teenagers/young adults, and mothers, through three commercials. All of the commercials have the same message of “I chose to be one less” and mothers who state “I chose to vaccinate my daughter because I want her to be one less”. The differences in the commercials are the age of the actresses. One of the commercials has primarily young adolescents and teenagers another has young adults and the third has mothers with their adolescent daughters. Despite the differences in the ages of the actresses in the commercials the message in each commercial is the same. Social marketing theory suggests that different populations have different interests and concerns and in order to successfully implement behavior change those interests and concerns need to be addressed when marketing to the respective populations (10). Clearly, adolescents, teenagers, young adults, and mothers have different concerns and interests, one message will not speak powerfully to each group.

Research conducted on smoking cessation has found that young adults often feel as though smoking cessation campaigns speak to teenagers and adults but not to them. The research participants claim that when the message does not speak to them, they do not listen (11). The young adults in this study said they would listen to messages that were pro-health and pro-youth and highlighted the immediate health effects experienced due to smoking. Gardasil commercials avoid stating that HPV is a sexually transmitted disease (STD). The smoking cessation research would suggest that Merck may convey a better pro-health and pro-youth benefit by emphasizing the immediate health problem that Gardasil prevents as opposed to the long-term health effect.

The message of “I chose….to be one less” is particularly inappropriate for speaking to the adolescent and young teenage population. Even if it gives a sense of empowerment to young girls, the truth campaign suggests is something youth want (12), unlike deciding to smoke, most young girls will not make the decision to get a vaccination, their parents will. An article in the New York Times (13) applauds this approach to reach young girls. The article claims the strength of the message is in depicting young girls who are making the decision to get this vaccine and take control of their lives while the mothers recite the side-effects of the vaccine. The article claims this makes the vaccination seem rebellious to the girls, but safe to the mothers. Although this may make young girls feel as though they can take control of their lives and that they have the power to choose, in reality they do not have that power. The fact that this ad campaign does not reach young girls in the intended manner was made clear while I perused to find Gardasil commercials. In addition to Merck’s commercials, I found numerous homemade commercials posted by young teenage girls making fun of the “One less” commercials (14, 15). The ad campaign has definitely spoken to them, but not in a successful manner.

The “I chose… have my daughter be one less” was most successful in getting the message to mothers about vaccinating their daughters. An article in the New York times stated that most mothers feel the large push for Gardasil to be mandatory and the awareness of the vaccination through the commercials make them feel like they are bad mothers if they do not get their child vaccinated (16). Merck’s “I Chose” message may have been successful in reaching mothers because it made them feel like bad moms if they did not choose to protect their daughters, but some research shows that despite this many mothers are still not convinced their daughters should receive the vaccination. Many mothers have questions about the long-term safety of the vaccination stating that their reasoning for not getting their daughters vaccinated is because they question its safety even though they agree with the concept of the vaccine (17, 18). Merck was correct in evaluating what sells to mothers, their child’s safety, but in order to sell safety the drug you are selling actually has to be safe.

When segmenting a market cultural differences are important to pay attention to as well. Unfortunately Merck, for the most part, ignored this. With an issue like HPV/cervical cancer it is particularly important to address cultural differences as a disproportionate number of Black and Hispanic women are afflicted by HPV and cervical cancer (19, 20, 21). In addition, it is important that these two populations are reached, because research has shown lower HPV awareness and knowledge among Hispanic and Black females (22). Other than having a few commercials in Spanish cultural and racial differences are not addressed through using another message. As Dr. Kilman pointed out in her lecture, “cultural differences are not just in the language” and Merck’s commercials do not account for those differences.

Failure in Message Framing

Merck’s advertising campaign for Gardasil is made up of a collection of commercials all with the message of “I Chose” and “One Less”. The adolescent girls, teenagers, young adults, and mothers in these commercials all recite lines about how they are choosing to be one less victim of cervical cancer, because they have chosen (or chosen for their daughters) to get the Gardasil vaccination, stating that it protects against 70% of HPV strains that cause cervical cancer. Not once in any of these commercials do they mention that HPV is an STD or how it is transmitted. A person who knows nothing about HPV may have no idea what puts them at risk for getting it and therefore may not be worried about the potential of getting the virus or cervical cancer. Clearly, Merck did not do their homework, because if they had they would have learned that many college aged women, one of their main target groups, are quite interested in receiving a vaccination for HPV after they have been educated about the disease, how it is transmitted, and the harm it potentially causes (i.e.; cervical cancer). After learning about the disease, not surprisingly interest in the vaccination increased among research participants who were more sexually active (23, 24, 25, 26). This is not unexpected most behavioral change models include the idea of perceived susceptibility (10, 27, 28, 29) for this reason. If a person feels at risk for something they are more likely to perform a preventive behavior. Given the findings of this research one would conclude that Merck would be more successful in reaching young adults if they framed their message as prevention for an STD that causes cancer as opposed to preventing cervical cancer. STDs are an immediate risk to sexually active people, but cervical cancer without the knowledge of what puts one at risk for it, is not.

Did Merck not do their homework or was there a reason behind their choice to frame their advertisements the way that they have? I cannot say for sure, but if I had to guess, I would say that they thought the public would perceive and react to their advertisements for Gardasil more positively if it was promoted as a cancer preventing vaccine as opposed to an STD preventing vaccine. Framing to achieve social change is based on communication at the level 1 stage of analysis. The level 1 stage includes peoples’ values and principles (30). Gardasil made the bet that the values and principles of their target audience (mothers of girls under 18 and woman 18-26) would be more satisfied and less compromised if their vaccine prevented cervical cancer instead of an STD. Beliefs about sexual activity and STDs vary quite a bit between different social groups in our society. Many people if led to believe HPV is an STD may have no interest in a vaccination to prevent it for fear that it may promote promiscuity or damage an abstinence only ideology (31). Cervical cancer on the other hand has less controversy surrounding it and most people would agree it should be prevented. Preventing cervical cancer probably appeals more to mothers than preventing their 11 year old daughters from getting an STD. However, recent research showed that more than 1 in 4 teenage girls (14-19 years of age) have an STD (21). It might be difficult for mothers to accept that their teenage daughters are at risk for STDs, but if Merck promoted this reality they may be even more successful in reaching both their target audiences.

How Merck’s Move to Mandate Gardasil Stigmatized the Vaccination

Based on the previous arguments the one group Merck was the most successful marketing to through framing and social networking theory were mothers. However, despite their success with mothers in those areas, Merck’s effort to make Gardasil mandatory angered many mothers/parents and caused the vaccine to be stigmatized, decreasing the benefit it could potentially provide for the public. Since the approval of Gardasil by the FDA in 2006, Merck has pushed for legislation to make the vaccination mandatory in at least 24 states (32). This clearly would be financially beneficial for Merck as a company, but also has the potential to improve the health of the public. Gardasil is an extremely expensive vaccination and not covered by all insurance plans, making the vaccine inaccessible to many people, but if the vaccine were mandatory this would no longer be an issue for many individuals (31). Despite the potential benefit to the public, Merck’s heavy involvement in pushing to make the vaccine mandatory led to the public viewing it as a personal agenda and not a public health effort (33).

The public debate that has ensued surrounding efforts to make Gardasil mandatory has led to the vaccine being stigmatized. According to stigma theory, which generally refers to a person or group of people being stigmatized, but is still applicable here, has five components that must be met for something or someone to become stigmatized: 1) distinguishing and labeling differences; 2) linking human differences with negative attributes; 3) separating “us” from “them”; 4) status loss and discrimination; and, 5) the dependence of stigma on power (34). Merck has successfully been able to achieve all five elements through attempting to make Gardasil mandatory and in the process caused fear and moral disbelief in their vaccination.

Most mandatory vaccinations are given in order to produce herd immunity, but Gardasil is only given to females and only protects against 4 strains of HPV, thus eradication of the disease will not be possible (i.e.; herd immunity is not possible). The vaccine is also different in that its transmission is dependent on behavior, it cannot be contracted unless there is sexual contact with another individual (33). Due to these two factors the first and third component of stigma theory are satisfied. The fact that the virus this vaccine is preventing is an STD links it to having a negative attribute, because many feel receiving the vaccination may promote riskier sexual behavior and/or disinhibition (31, 35, 36). Because the vaccine prevents against a virus that is transmitted through sexual activity, some parents view the mandate as taking away from their power to make decisions about their child’s health. Taking autonomy away from parents regarding the health of their children is another negative attribute of attempting to mandate Gardasil. For these two reasons the second component of stigma theory is satisfied. The debate about the behavioral effects this vaccination may have on young girls has caused it to lose status, but beyond that, the debate has caused more in depth scrutiny of the health benefit of the vaccination. This scrutiny has led to many policy makers and people in the health care industry to publicly question whether the vaccine is as beneficial as the public once perceived (16, 33, 37). The increased public scrutiny is not only widespread, but being proffered by groups that hold a lot of power (e.g.; publications like the New York Times, various scholarly journals, conservative advocacy groups, etc.). The presence of the criticism by powerful entities has led to even further status loss and thus fulfills the fourth and fifth components of stigma theory.

Merck’s attempt to make Gardasil mandatory either sprung from a desire to improve the health of the public or possibly their pocket book. Regardless of their intended desire, their plan backfired. Whether the scrutiny is justified or not it is causing many people to think twice before receiving the vaccination or taking their daughters to receive the vaccine (17, 18, 39).


I personally believe that Gardasil is a good vaccine and I think that a lot of people can benefit from it, but the manner in which Merck has advertised this vaccine promotes false knowledge about HPV and a false sense of security. If Merck really wanted to do a public service they would be upfront about the facts of HPV, because the facts they leave out are facts that speak to people who are at risk. Their carefully framed advertisements, marketing, and political activity attempted to portray Gardasil in a manner that would sell to certain consumers, not necessarily to promote public health, at least not the entire public that would benefit from Gardasil. Unfortunately for them, but possibly fortunately for the health of the public, their efforts to mandate the vaccine brought Gardasil and HPV under public scrutiny. There are many concerns, safety and behavioral, about Gardasil that have come to light due to the controversy surrounding Gardasil. Firstly, the controversy has made the public more aware about how HPV is contracted and it has made consumers more informed about the potential side effects and unknown long-term effects of the vaccine. It should not take the failed attempts of a drug company to sell a vaccine to make the public aware of the most commonly contracted STD that has the potential to lead to cervical cancer. Now that Merck has gotten the public’s attention about HPV, I think it is time for public health practitioners and other medical professionals to take this opportunity to provide accurate, unbiased information on this topic to the public.

A Better Intervention

The new Gardasil campaign should have two basic commercials as well as more tailored commercials that are aired in various areas that target certain cultural issues that should be addressed in order to effectively reach all segments of the market. One commercial should be tailored toward mothers while the other should be tailored toward young adults. The overarching theme/message in these commercials should be that Gardasil protects against HPV, a sexually transmitted disease that can cause cervical cancer. How this message is packaged though will differ depending on the audience. The commercials that are intended to speak to mothers will emphasize protecting their daughters, address the vulnerability of their daughters, and highlight how safe the vaccine is. Mothers will be given facts not only about HPV, how it is spread, and how Gardasil can help, but will also be given statistics about it’s prevalence among young girls and the prevalence of sexual activity among young girls. The tagline for this commercial would be, “Protect your daughter from HPV, if you don’t make the decision to protect her who will?” This message in the commercial should be delivered by a doctor. There will also be information in this commercial about the CDC covering Gardasil as part of the Vaccines for Children Program.

The advertisement for young adults will emphasize that HPV is an STD and that it is spread through sexual activity. The message conveying what HPV is and its prevalence will be framed in a positive manner (i.e.; emphasizing that if they get the vaccine they decrease their chances of getting HPV/cervical cancer vs. if they do not get the vaccine they are more likely to get HPV/cervical cancer) and should discuss how it effects the population as a whole, not just them as an individual. The tagline for this ad should be along the lines of, “Do the right thing for yourself and your peers - get vaccinated to protect against HPV”. In addition to the information about the vaccination there should be honest facts about the fact that the vaccination only protects against the three strains of HPV that cause 70% of cervical cancers and therefore using condoms and getting routine pap smears are still necessary. This is similar to the Valtrex commercials that state that one should still practice safe sex even if they are taking the medication, because it is not 100% effective.

An example of the type of culturally sensitive intervention that could be used is one that addresses the Hispanic young adult population. The message should be heavy on the educational side and should emphasize the issue of silence surrounding sexual behavior. This would help to make HPV transmission/vaccination a less taboo topic, therefore making the HPV education and the receiving the HPV vaccination more acceptable. A tagline message could read, “Break the silence and protect yourself”.

In addition to these commercials public policy makers and Merck should work toward somehow requiring insurance providers to cover Gardasil as opposed to making it mandatory.

Improved Use of Social Marketing Theory

What differentiates Social Marketing Theory (SMT) from other behavioral theories is the role of market segmentation and appropriate message targeting toward that segment (10). The above intervention does a better job of appropriately segmenting the market compared to Merck’s segmentation. The new intervention has two basic categories, mothers and young adults. Merck had an additional segment: the adolescent/teenage girl independent of her mother. Due to the fact that a child who is not 18 cannot make the decision to get a vaccination independently of her parents, this market segment was unnecessary and unproductive. SMT states that a product needs to be created that will sell to the target population (10). In this case, product that is being sold to mothers is not simply the vaccination, but also the safety of their child. Research shows that mothers are concerned about preventing cervical cancer in their daughters, but they are also concerned about the safety of the vaccine in and of itself (17, 18, 40, 41) Research also shows that mothers’ attitudes about HPV are influenced positively if a doctor promotes its use (40, 42). The original Merck commercials strongly emphasize that the vaccine will prevent cervical cancer, but make little to no mention of the safety of the vaccination. The Merck commercials also only show mothers and children speaking. This commercial would have a doctor giving the message. Another important concept in SMT is the price involved. Price can be thought of as actual cost, but can also be thought of as the price of not getting the vaccination (10). The actual message of, “Protect your daughter, if you don’t who will?” is supposed to play on the idea of price. If you, as a mother, do not take control you may pay the price of losing your daughter to cervical cancer, because who else will take on that responsibility. The place concept in SMT addresses access and availability of the intervention, which speaks more to actual price of the vaccination. If the vaccine is not accessible or affordable this is a perceived barrier. Perceived barriers are an aspect that is central to many behavior change theories (10, 27, 28, 29). Gardasil is expensive, which could be thought of as a barrier as well. Mentioning that it is covered by the vaccines for children program will help to diminish the barriers perceived by mothers who are interested in getting the vaccination for their children. Cost is not mentioned once in the original Merck commercials.

The product being sold to the young adults is one of immediate gratification. Young adults are not always forward looking and live in the here and now. Young adults will listen to messages that are pro-health and pro-youth and speak to the immediate positive impacts that a health behavior will have (11). Creating a commercial that is heavy on the true facts about HPV, how it is spread, and the immediate impact the HPV vaccination can have on preventing the contraction of HPV will be more effective than telling young adults to get the vaccination to prevent cervical cancer. It is not just SMT that supports this, but all the health belief models that include perceived susceptibility speak to the importance of having knowledge about what puts one at risk for a disease or outcome (10, 27,28,29). Another factor that the revised commercial accounts for is place (10). As mentioned, Gardasil is not inexpensive, and may not be available to everyone Young adults are not eligible for the Vaccine for Children Program. Thus, this commercial also provides other tools for protection by discussing the role that safe sexual practice can play. This helps to promote self-efficacy, an important tool in promoting behavior (43), by giving young adults other tools to protect themselves and making prevention against HPV more attainable.

The product being sold to the Hispanic population discussed is one of openness surrounding HPV. Research about Latina women shows low knowledge about HPV and participation in unsafe sexual practices due to a lack of education, because of the cultural belief that sex is something that is private and should not be discussed (44). However, in this same research the participants recognized that their lack of knowledge could jeopardize their health and expressed willingness and interest in educational campaigns that addressed the issue of silence (44). The original Merck commercials diversified their commercials through putting culturally diverse people in the commercials. Research shows this can be useful (45), but it does not get at the heart of why people do not accept the vaccination.

More Effective Use of Framing

Framing to achieve social change occurs at the level one stage of analysis. This stage includes peoples’ values and principles (30). The new messages more appropriately target the values and principles of the people being targeted in the market segmented commercials. According to research mothers value the following when making the decision to vaccinate their daughters against HPV: the vaccines effectiveness, the likelihood of HPV infection, and physician recommendations (40, 41). The new message touches on all these values through emphasizing the vaccines safety, providing statistics about sexual activity and prevalence of HPV among young girls, and having physicians offering the message. If anything the Merck commercials shied away from all of these things by not mentioning safety, not connecting HPV to being an STD, and they definitely did not bring to light through statistics why young girls were at risk for getting HPV.

Young adults show more interest in the vaccination if they are more sexually active, because they feel more at risk for the disease (23,24,25,26). Framing the new commercial to be about HPV as an STD that causes cancer as opposed to a virus that causes cervical cancer will help to increase perceived susceptibility and interest in the vaccination (10, 27, 28, 29). Including information in the commercial about how to protect against HPV if you cannot get the vaccination is also important, because it improves self-efficacy, which is an integral part of Social Cognitive Theory (SCT) that helps to promote behavior change (43). In addition the tagline in this message, “Do the right thing for yourself and your peers - get vaccinated to protect against HPV” is also a crucial part of the framing. Research done on how to promote vaccination behavior among college aged students using message framing found that a positive frame that emphasizes how the vaccination will help oneself and others (i.e.; help yourself and your peers) was more effective than a negatively framed message that focused only on the effects on oneself (46). The same results were found in a study conducted about intentions to get an avian flu vaccination. People were more likely to get the vaccination if it was framed as being beneficial to themselves and society (47). Simply by stating that HPV is an STD makes this intervention better than Merck’s, but this intervention also takes the next step and frames the issue to be highly specified for the particular population of interest.

The research found regarding college aged Latina women suggests that their values are in conflict. This group showed an interest in health, but also a cultural belief in silence regarding sexual behavior (44). However, the willingness to challenge this cultural belief in order to promote education suggests that a message that is framed in a manner that emphasizes education while challenging the silence may be the most effective way to reach this particular population. Again, even considering how culture plays a role in vaccine acceptance is more than the original Merck commercials attempted to do.

Getting Rid of Stigmatization Surrounding the Gardasil Vaccine

As explored in the critique of this paper, the main benefit to making the Gardasil vaccination mandatory was that it would help make it accessible to people who could not otherwise afford it (31). Beyond this benefit though it also managed to stigmatize the vaccination by fulfilling the five components of stigmatization: 1) distinguishing and labeling differences; 2) linking human differences with negative attributes; 3) separating “us” from “them”; 4) status loss and discrimination; and, 5) the dependence of stigma on power (34). Of these five components the one that makes the rest of them valid in the case of Gardasil is the first one. By trying to make Gardasil mandatory it distinguished it as being different from other vaccines. It would have been the only mandatory vaccination in existence that would not be able to promote herd immunity and that prevents a disease that is behavior based (33). However, the benefit of accessibility due to mandating the vaccine is a valid one. Thus, the reason the new campaign proposes that Merck and public policy makers try to pass a law that requires insurance companies to cover Gardasil as opposed to making it mandatory. A barrier to receiving the vaccination that is mentioned by all people, regardless of market segment, is the cost (31, 48). Another reason for stigmatization that was discussed in the critique was due to the fact that there were many articles in the media questioning the safety of Gardasil and the backlash this had on mothers worrying about safety. As mentioned, the current intervention does a better job of curbing the issue of safety by including a doctor in the commercials and discussing safety as part of the advertisement.


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