Excerpts from the research paper titled ‘Media Framing of Human Papillomavirus (HPV) Health Issues and HPV Vaccine-Related Sentiment in English Language News Media in India (2015-2018)’
India records a high incidence of Human Papillomavirus (HPV)-related infections and cancers, with cervical cancer being the second biggest cause of mortality among women with cancer in the country. Immunization against the high-risk HPV serotypes can efficiently prevent related diseases. The HPV vaccine was recommended to be added in the Universal Immunization Program (UIP) of India by the National Technical Advisory Group on Immunization (NTAGI) in 2017. However, following a controversial vaccine trial in 2009 and a pending decision on a related legal case, the Government of India has refrained from including the vaccine in the UIP.
HPV incidence and HPV vaccine policy in India
Human Papillomavirus (HPV) is a common virus that is present abundantly in the environment and is among the most common sexually transmitted infections (STI). Scientific research has established that certain types of high-risk HPV strains, specifically the HPV serotypes 16 and 18, are responsible for cancers of cervix uteri, penis, vulva, vagina, anus and oropharynx in women as well as men. The incidence of HPV related cancers, especially cervical cancer among women, is very high in India. Approximately, 453.02 million women aged 15 and older are at the risk of developing cervical cancer in India.
Every year, 96922 women are diagnosed with cervical cancer, while 60078 succumb to the disease (ICO/IARC HPV Information Centre, 2018). Cervical cancer is the second most common cause of cancer-related deaths among women in India. As a result of long-term tobacco use and concurrent HPV infections among the population, the rate of head and neck cancers associated with HPV infections is also expected to rise in India (Gupta, Johnson, & Kumar, 2016).
The probability of acquiring HPV infections and the severity of HPV-related diseases are determined by several medical and non-medical factors. The non-medical factors include environmental factors, such as, polluted environment, poor sanitation, and lack of clean water for cleaning and consumption; behavioral factors, such as, having unprotected sex, having multiple sex partners, tobacco use and poor maintenance of health and hygiene. Socio-economic and political factors like income, social status, gender, social rituals and norms, access to healthcare and other amenities, political institutions, nature and ideology of government and bureaucracy, corruption, and public policy, among others are also significant determinants of HPV-related health status. Several structural factors within the field of medicine, such as, research, knowledge and training, health infrastructure, administration, services, etc, and biological/physiological factors, such as, gender, age, genetics, prevailing diseases, among others, also determine an individual’s HPV-related health status. An overall poor health, arising from a combination of certain specific factors or several medical and non-medical determinants of health puts an individual at a high risk of contracting HPV infections and HPV-related diseases.
Timely immunization with the HPV prophylactic vaccine, along with regular HPV screening, can help prevent HPV infections and HPV-related cancers (Schiffman, Wentzensen, Wachold, Kinney, Gage, & Castle, 2011; Ronco, et al., 2014; Petrosky, et al., 2015; Zhai & Tumban, 2016). The safety and the efficacy of the HPV vaccine have been confirmed by the results of large trials across the different countries and health contexts. Currently, there are three types of approved prophylactic HPV vaccines available for use: the bivalent (against HPVs 16/18), the quadrivalent (against HPVs 6/11/16/18) and the 9-valent vaccines (against HPV 6/11/16/18/31/33/45/52/58).
In 2017, the National Technical Advisory Group on Immunization (NTAGI) recommended introducing the HPV vaccine in the Universal Immunization Programme (UIP) of India (NTAGI, 2017). In 2009, a feasibility study of the HPV vaccine conducted by an American non-profit organization, Program for Appropriate Technology in Health (PATH), in partnership with the provincial governments of the Indian states of Andhra Pradesh and Gujarat, hit a roadblock following the deaths of eight pre-adolescent girls, who were among the 24,000 girls who had been administered the vaccine during the study. The Parliamentary Standing Committee of the Ministry of Health and Family Welfare (MHFW), India, highlighted ethical violations committed during the trial conducted jointly by PATH and Indian Council of Medical Research (ICMR), which was one of PATH’s technical partners for the study in India. The study was abruptly stopped, even though it was found that the deaths of the adolescent girls were not related to immunization with the HPV vaccine (Larson, Brocard, & Garnett, 2010). In 2012, a writ petition filed in the Supreme Court of India called for revoking licenses of the two HPV vaccine manufacturers, Merck Sharp & Dohme (MSD) and GlaxoSmithkline (GSK), citing that the then Drug Controller General of India (DCGI) had allegedly approved the vaccine by the manufacturers without conducting proper clinical trials and without any evidence of the vaccine’s efficacy and safety. What with the decision still pending with the apex court of India, the Government of India has suspended its decision on introducing the vaccine by the two manufacturers in the UIP. However, the Indian states of Delhi and Punjab have introduced the vaccine for adolescent girls in their immunization program as an optional vaccine (Narayanan, 2018). An Indian pharmaceutical company is currently in its final stage of clinical testing of a quadrivalent HPV vaccine. It remains to be seen whether the HPV vaccine made by the Indian manufacturer, after completing trials and its market launch, will be adopted in the UIP or not.
This study is an analysis of the media coverage of HPV-related issues and HPV vaccine-related sentiment in English language news media in India from 2015 to 2018.
HPV and media coverage
Health behavior associated with the causes of HPV infections, and vaccine uptake in a population are influenced by the public perception of the risks of HPV infections and beliefs related to the efficacy of HPV vaccine. The news media plays a crucial role in forming a public perception of risks and health beliefs by disseminating information about health issues and policies.
In India, awareness about HPV- related diseases and HPV vaccination is low (Hussain, et al., 2014; Rashid, Labani, & Das, 2016; Chawla, Chawla, & Chaudhary, 2016). Recent studies have also shown resistance to the HPV vaccine, citing fears about post-vaccination complications and the prohibitively high cost of vaccine (Singh, et al., 2018). However, there’s evidence that attitude towards the HPV vaccine, and associated risk-benefit beliefs among parents of adolescents can be modified through strategic messages which focus on highlighting the risks of HPV infections and the efficacy of the vaccine against HPV-related diseases (Degarege, et al., 2019).
While research on HPV and HPV vaccine-related messages in Indian media is lacking, significant presence of negative information regarding vaccines and immunization has been found on Indian online and web-based media. The negative information found is primarily coverage of adverse events reporting – from minor allergic reactions to rare deaths – without any proof of causality, or is about shortage of vaccine and social resistance to immunization (Das & Singh, 2018). Research shows that negative news coverage can generate a negative information loop, beginning with a negative media report about a vaccine and leading to a spike in adverse events reporting post-vaccination. Consequently, there is a drop in vaccine uptake, inviting more negative media coverage. A Denmark-based study (Suppli, Hansen, Rasmussen, Valentiner-Branth, Krause, & Mølbak, 2018) found a significant negative correlation between negative media coverage of vaccines and vaccine uptake, coinciding with a spike in Google search activity related to the side effects of the HPV vaccine, Gardasil, manufactured by MSD.
ANALYSIS AND DISCUSSION
A prevalence of prevention and awareness messages related to HPV-related issues and the HPV prophylactic vaccine in the HPV-related coverage by the English language news media in India was found. Prevention messages focusing on the HPV vaccine largely carried a positive sentiment towards the vaccine, while 2 out of the total 4 news items in the data set with a negative sentiment were also found in this subset. News items carrying awareness messages were among the ones with the most neutral sentiment or no mention of the HPV vaccine, while the remaining 2 out 4 negative sentiment news items were also found in this sub-set. These findings suggest that the risk-benefit messages related to the HPV vaccine are frequently framed within the prevention and awareness health discourse disseminated by the media.
The data reveals coverage of the HPV- related issues and the HPV vaccine to be temporally connected. However, thematic framing was used in news items carrying contested position or negative sentiment towards the HPV vaccine. It was found that 3 out of 4 stories with a negative sentiment towards the HPV vaccine appeared in the news media after officials of an economic affairs-related outfit that is affiliated with a right-wing political organization in India, wrote to the Prime Minister of India’s office in December 2017, against the implementation of the HPV vaccine in the UIP, as a reaction to the NTAGI recommendation to include the vaccine (Mathew & Ghosh, 2017). The remaining one news item with a negative sentiment, written by a guest writer for the news media, was an opinion-based article about ethical issues in clinical trials conducted in India. All the stories with the negative sentiment included references to the 2009 HPV vaccine trial controversy in India, and associated vaccine inefficacy with the alleged ethical violations in the trials. The stories related to the controversial letter to PMO also cited the high cost of the vaccine as a drawback. The deaths of the pre-pubescent girls during the 2009 HPV vaccine trial were mentioned without clearly associating them with HPV immunization and without providing evidence for or against the safety of the vaccine. Almost all news items with the contested sentiment towards the vaccine carried references to the controversial trial by PATH in 2009.
Health behavior was the most frequently referenced determinant of HPV-related health status. News items that framed the HPV-related issues using the health behavior DOH mentioned personal hygiene, sexual behavior, specifically having multiple sex partners and unprotected sex, as a high-risk factor in HPV-related diseases. References to general risk behaviors associated with cancer incidence, such as, smoking, tobacco use and unhealthy lifestyle, etc, were also present. Studies about coverage of the HPV vaccine in the US and British news media reveal mediation of links between sexual behavior and immunization with the HPV vaccine by the media. The news media coverage primarily argued against any causal relationship between HPV vaccination and sexual behavior that might lead to rise in promiscuity following immunization, (Forster, Wardle, Stephenson, & Waller, 2010; Casciotti, Smith, Tsui, & Klassen, 2014). However, no such mediation of links between the HPV vaccine and sexual promiscuity was present in the news items sampled for this study.
An absence of non-authoritative sourcing and attributions, and the dominating presence of authoritative sources of news items and attributions within the news items reveal the media’s use of authoritative frames in its coverage of the HPV issues. The public, the patient or the individual opinion and voice was absent. Exemplification, which has shown to influence public opinion about issues related to health and society (Zillmann, Gibson, Sundar, & Perkins, 1996), was absent in the authoritative framing of the HPV issue.
The HPV vaccine-related news items were mostly framed within the economic DOH, followed by the health behavior DOH. This suggests that the media’s perception of economic factors, such as the cost of the vaccine, affordability of health services and interventions in a low-income country like India, and its perception of behavioral factors, such as, sexual activity, hygiene and lifestyle, etc, influences its coverage of the HPV vaccine issue. News items related to cervical cancer and other HPV-related cancers were mostly framed within the health behavior DOH, and almost never within the environmental DOH frame. The implication of this framing can be studied in future research related to HPV-related media coverage. It was also found that the HPV-related issues were routinely covered in a national or global context, while regional and local perspectives were sparse.
The study revealed a predominantly positive sentiment towards the HPV vaccine in the media coverage of the issue. The news items with the negative or the contested sentiment towards the vaccine were thematically framed by the media. References to previous adverse events’ reportage, the vaccine trial controversy, the cost of vaccine and negative perception related to the vaccine, appeared as the most significant discursive elements in the thematic framing of the HPV vaccine issue. All news items maintained authoritative sourcing and attribution pattern. The association between the presence of positive attitude towards the HPV vaccine and authoritative framing using authoritative sources and attribution can be further investigated.
Becker (1986) stated that the media usually levied responsibility on the individual for his health and wellbeing, while placating the role of society, state, etc, in preventing and curing a disease. The prevalence of an authoritative framing of the HPV-related issues using behavioral determinants of health by media, as seen in the studied sample, necessitates a critical examination of attribution of responsibility and its affect on public policy, public perception and health behavior. Since the results of this study are based on a selected sample of the English language news media in India, it is recommended that the results be used as probes for studying HPV-related coverage in the vernacular press, online media and social media as well.
International Journal of Scientific and Research Publications, Volume 10, Issue 1, January 2020. ISSN 2250-3153.
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