https://orcid.org/0000-0001-9139-7645
ABSTRACT
This study aimed to investigate the association between political ideology and awareness of HPV and HPV vaccine among US adults. Study data were derived from Health Information National Trends Survey 5 Cycle 4, a 2020 cross-sectional survey of US adults. Multivariable logistic regressions were conducted to examine the association between political ideology with HPV and HPV vaccine awareness. A total of 3418 adults participated in the study, with the majority being non-Hispanic White individuals and women. The results showed that 66.1% and 62.3% of the participants were aware of HPV and HPV vaccine, respectively. A total of 36.9%, 29.7% and 33.4% of the population reported moderate, liberal and conservative political ideologies respectively. Awareness levels were highest among liberals, with 77.1% and 72.7% reporting awareness of HPV and HPV vaccine respectively. Multivariable logistic regression analysis revealed that liberal participants were more likely to be aware of HPV (aOR, 1.94; 95% CI, 1.25–3.00), and HPV vaccines (aOR, 1.94; 95% CI, 1.37–2.74) compared to moderates. Also, liberals had higher odds of HPV (aOR, 2.41; 95% CI, 1.65–3.51), and HPV vaccine awareness (aOR, 1.91; 95% CI, 1.29–2.83) compared to conservatives. However, there was no significant difference in awareness between moderates and conservatives. Study findings point to an association between individuals’ political ideology and HPV awareness. Further research is needed to understand the intricacies on how political ideology impacts HPV awareness. Overall, results highlight the need to incorporate individuals’ political ideologies in interventions geared toward increasing the awareness and uptake of HPV vaccination.
Introduction
The burden of Human papillomavirus (HPV)-associated cancers in the US is significant, with an estimated 47,199 new cases occurring each year.Citation1 Despite the availability of a safe and effective vaccine, HPV vaccination uptake in the US remains suboptimalCitation2 which has prompted public health campaigns to increase HPV awareness as a means to increasing vaccination uptake rates. However, the success of these interventions has been limited, as a study shows the awareness of HPV and HPV vaccine has stagnated in the US.Citation3
The relationship between politics and public health is well documented.Citation4 Political ideology has been shown to influence health behaviors and practices and may also have an impact on knowledge and awareness of health issues. A study found an association between the political affiliation of governors and COVID-19 incidence, mortality, and testing.Citation5 Another study found that political ideology was associated with an individual’s support for tobacco control policies.Citation6 As it pertains to vaccination behaviors, a study found an association between individuals’ political ideology and intentions to receive pertussis, measles, and influenza vaccines, with conservatives less likely to receive these vaccines than other individuals.Citation7 Similarly, another study found greater confidence in the HPV and COVID-19 vaccines and a higher odds of vaccination intent among Democrat parents compared to Republicans.Citation8
Awareness of HPV and the benefit of HPV vaccination in prevention of HPV-associated cancers is crucial for the uptake of HPV vaccination. However, there is a paucity of studies examining the relationship between political ideology and HPV awareness. Prior studies of this association were conducted more than a decade ago.Citation9,Citation10 More so, this relationship has not been evaluated in the COVID-19 era, particularly in light of the rising vaccination hesitancy since the pandemic.Citation11,Citation12
Understanding the association between political ideology and HPV awareness is important for tailoring public health interventions to different political groups to increase vaccine uptake. Such interventions may help to address the current suboptimal HPV vaccination rates in the US and ultimately reduce the burden of HPV-associated cancers. This study aims to explore this association and provide valuable insights for public health practitioners to design effective interventions that consider the influence of political ideology. Considering the findings of the above referenced studies, we hypothesize that i) individuals who identify as conservatives will have lower levels of awareness of HPV and HPV vaccine compared to liberals and moderates, and ii) liberals will have increased odds of HPV and HPV vaccine awareness, compared to conservatives and moderates.
Methods
We queried data from the Health Information National Trends Survey (HINTS) 5 Cycle 4 (H5C4), conducted from February 24–June 15, 2020.
HINTS is a nationally representative survey of non-institutionalized civilian US adults administered by the National Cancer Institute (NCI) every three years since 2003. The HINTS collects information on cancer prevention, cancer diagnosis, cancer-related beliefs, screening and health behaviors. A total of 15,347 households received the questionnaires in H5C4 and the response rate was 36.7%. Additional information on HINTS data collection and methodologies including the sampling and weighting process can be obtained at https://hints.cancer.gov/data/methodology-reports.aspx. HINTS 5 cycle 4 data are publicly available and de-identified. Therefore, our study is considered exempt from our local institutional review board assessment or review by the US National Institute of Health Office of Human Subjects Research Protections. We followed the Strengthening the Reporting of Observational Studied in Epidemiology (STROBE) guidelines.
Measures
Exposure
The main exposure of interest was participants’ political ideology. Participants were asked to identify their ideology with the following prompt: “Thinking about politics these days, how would you describe your own political viewpoint?” Response options included very liberal, liberal, somewhat liberal, moderate, somewhat conservative, conservative, and very conservative. Very liberal, liberal, and somewhat liberal were collapsed into a single response category (liberals), and very conservative, conservative, and somewhat conservative were also collapsed into a single response category (conservatives).
Outcome
Outcomes of interest were the awareness of HPV and HPV vaccine which were ascertained based on responses of “yes” or “no” to the survey questions – “Have you ever heard of HPV? HPV stands for Human Papillomavirus. It is not HIV, HSV, or herpes.,” and “A vaccine to prevent HPV infection is available and is called the cervical cancer vaccine or HPV shot. Before today, have you ever heard of the cervical cancer vaccine or HPV shot?” respectively.
Study covariates
Covariates included in this study were informed by prior literature delineating factors associated with HPV and HPV vaccine awareness.Citation3 The specific sociodemographic variables and health-related variables included in the study were age (18 to 34 years, 35 to 49 years, 50 to 64 years, and 65 years or older), sex, race/ethnicity (White, Black or African American, Hispanic, and others), educational level (high school graduate or less, some college, college graduate or postgraduate), household income (less than $20,000, $20,000 to less than 35,000, $35,000 to less than 50,000, $50,000 to less than 75,000, and $75,000 or above), having a regular provider, presence of comorbidities (one or more of the following conditions: diabetes mellitus, hypertension, heart disease, lung disease, or previous cancer diagnosis), and rural-urban residence.
Statistical analysis
All statistical analyses were performed using the “svy” command in the Stata 17.0 statistical software (StataCorp LP, College Station, Texas, USA). Final person weights and jack-knife replicate weights provided within the H5C4 dataset were used to derive national-level estimates. Descriptive statistics using chi-squared tests were conducted for the entire study sample. Frequencies and weighted percentages were estimated for the overall adult population by age, sex, annual household income, race/ethnicity, level of education, having a regular provider, presence of comorbidities, and rural or urban residence.
Frequencies and weighted percentages of political ideologies were also estimated by HPV and HPV vaccine awareness using chi-squared tests. Multivariable logistic regression analyses were conducted to examine the association between political ideology with HPV and HPV vaccine awareness among the study population. To enable a direct comparison of outcomes between political affiliations, multivariate logistic regressions were performed, with the referent category for the exposure variable being varied. All regression models were controlled for sociodemographic and health-related variables, and statistical significance was set at p < .05.
Results
Overall, 3,865 respondents were included in HINTS 5 cycle 4. A total of 3,418 adults aged 18 or older had provided full data on political ideology, HPV and HPV vaccine awareness, and thus were eligible for inclusion in our study.
Participant characteristics
About 50.2% of the population were female, 63.5% white, 31.3% were college graduates, 43.6% earned over $75,000, and 88% were urban residents (). A total of 2159 (66.1%) and 2080 (62.3%) were aware of HPV and HPV vaccine, respectively. Furthermore, 1179 (36.9%) self-reported as moderates, 1044 (29.7%) as liberals, and 1195 (33.4%) as conservatives.
Table 1. Sample population demographic characteristics: sample N = 3,418.
Awareness levels were highest among liberals, with 77.1% and 72.7% reported having awareness of HPV and HPV vaccine respectively, compared to 63.6% and 58.3% of moderates who reported awareness of HPV and HPV vaccine respectively, and 59.0% and 57.6% of conservatives who reported having awareness of HPV and HPV Vaccine respectively (). However, when stratified by respondent sociodemographic characteristics, HPV awareness levels by political ideology varied significantly. For example, conservatives in rural regions had higher levels of awareness of HPV (15.6) and HPV vaccine (16.6) compared to liberals (7.3 and 8.2, respectively) and moderates (11.5% and 13.1%) respectively. Whereas in urban regions Liberals had higher levels of awareness of HPV (92.7%) and HPV vaccine (91.8%) compared to other political ideologies. Variations in HPV awareness were also reported for age, education and race, while variations in HPV vaccine awareness were also reported for age ().
Table 2. Prevalence of HPV and HPV vaccine awareness by political ideology.
Table 3. Sample demographic distribution by political ideology, HPV and HPV vaccine awareness.
Association between political ideology with HPV and HPV vaccine awareness
After controlling for covariates, compared with moderates, liberals were more likely to be aware of HPV (aOR, 1.94; 95% CI, 1.25–3.00), and HPV vaccines (aOR, 1.94; 95% CI, 1.37–2.74) respectively. Also, compared to conservatives, liberals had higher odds of HPV (aOR, 2.41; 95% CI, 1.65–3.51), and HPV vaccine awareness (aOR, 1.91; 95% CI, 1.29–2.83). The odds of HPV (aOR, 0.81; 95% CI, 0.56–1.17) and HPV vaccine (aOR, 1.02; 95% CI, 0.73–1.41) awareness did not differ significantly when comparing conservatives to moderates ().
Table 4. Logistic regression for the association between political ideology with awareness of HPV and HPV vaccine.
Discussion
The results of this nationally representative study of US adults provide evidence supporting the role of political ideology in shaping population-level awareness of HPV and the HPV vaccine. Specifically, our findings confirmed our study hypothesis by demonstrating that among the political ideologies examined, conservatives had the lowest levels of awareness regarding HPV and the HPV vaccine. Also, liberals exhibited significantly higher odds of HPV awareness compared to both conservatives and moderates. These results underscore the potential impact of political ideology on public awareness of HPV and the vaccine.
Our study’s findings align with a previous smaller-scale study focused on females, which reported lower HPV knowledge scores among politically conservative respondents.Citation10 Another study observed that liberals and conservatives showed slightly higher levels of awareness of the HPV vaccine compared to moderates.Citation9 However, it is worth noting that these studies were conducted around a decade ago, and no recent nationally representative studies have been conducted on this topic. Additionally, our study was conducted during the height of the COVID-19 pandemic, between February and June 2020, a period characterized by increased polarization and vaccine hesitancy. Given these circumstances, our study findings carry significant public health implications.
Historically, politics has played a significant role in the context of HPV vaccination such as the politicization of HPV vaccine introduction and the polarizing debate over school HPV vaccination mandatesCitation13–15 Previous studies have shown lower HPV vaccination coverage rates in conservative states,Citation16 and significantly higher vaccination coverage in blue compared to red states.Citation17 In light of our study finding of lower HPV vaccination awareness among conservatives, suboptimal HPV awareness could be a potential contributor to lower HPV vaccination uptake in conservative states.
HPV awareness has stagnated in the US, findings of our study suggest that political ideology may be a potential contributor. The index study of HINTS reports a very slight increase in HPV vaccine awareness (at 62.3%), while a National HIV Behavioral Surveillance study reported awareness at 53.2%, suggesting population awareness levels remain sub-optimal.Citation18 In recent years, vaccination efforts globally have been negatively impacted by political polarization, with political opinions and ideologies becoming key factors in vaccine uptake.Citation19–21 The COVID-19 pandemic has further exacerbated this divide,Citation20–22 with misinformation campaigns by anti-vaccination groups targeting individuals based on their political ideology and affiliation.
Our finding of differences in the awareness of HPV by political ideology is concerning. This variation in HPV awareness by political ideology may be explained by a number of factors including contrasting media framing and coverage of HPV vaccine on conservative versus liberal media outlets.Citation9 This keys into the historical relationship between HPV vaccine and politics and includes an era characterized by the highly politicized rhetoric around the approval review process, its promotion through a nationwide campaign directed at state legislatures, discussions around mandating the vaccine for school children and the lobby efforts that went into this. As a result of this process, many parents’ first exposure to information about HPV came through partisan news outlets, which may have influenced their attitudes toward the vaccine. The involvement of advocacy groups in promoting the HPV vaccine, along with the decision by some states to mandate the vaccine for school enrollment, created a highly charged political environment in which the vaccine became a subject of controversy. Partisan news outlets further amplified this controversy, often presenting the vaccine in a highly polarized manner that emphasized its potential risks and downplayed its benefits.Citation13,Citation23
It is worth noting that certain conservative views regarding HPV vaccination are rooted in misconceptions,Citation24,Citation25 particularly the belief that HPV vaccination is directly linked to sexual activity. These misperceptions have been perpetuated by conservative media outlets and influential political figures, and there is growing concern that this has the potential to affect clinical practice of clinicians who share similar ideologies. A study found significant variations in the care provided by physicians with different political affiliations on politicized health issues.Citation26 Therefore, it is possible that some healthcare providers, may feel uncomfortable engaging in discussions about HPV due to the association of the topic with these misperceptions, which may consequently impact HPV awareness. Another interesting finding of our study was that conservatives who reside in rural regions had higher HPV and HPV vaccine awareness than their political counterparts. This may be due to the fact that rural-dwelling conservatives have limited media options and access to the internet and social media, hence less exposed to misinformation campaigns.
Furthermore, pharmaceutical companies are an important stake holder in HPV vaccine promotionCitation27 and play a central role in increasing HPV vaccine awareness.Citation28 A study found that most parents and provider became aware of HPV vaccine through drug company advertisements.Citation28 It is possible pharmaceuticals may spend more advertisement funds on liberal media outlets, liberal states and/or states that have vaccination mandates, as this will likely result in greater yield and profitability – given research showing higher HPV vaccination rates in liberal states.Citation16,Citation17 However, if this holds true, it may further perpetuate low awareness in conservative states.
This study has several limitations that should be taken into consideration. Firstly, it is important to note that the HINTS survey used in this study is cross-sectional in nature, as such causal relationships cannot be established based on the findings. Another potential limitation is that the estimation of lack of HPV-related awareness may be prone to overestimation. This is because individuals may provide non-affirmative responses to survey questions assessing HPV-related knowledge due to factors other than simply lacking knowledge.Citation29 These factors could include misunderstanding or misinterpretation of the questions.Citation29 Additionally, certain cycles of the HINTS survey experienced low response rates, which introduces the possibility of low-response bias.Citation30 However, it is important to note that the HINTS survey addresses this potential bias through its modality coverage and survey sampling techniques. Despite these limitations, the findings of this study contribute valuable insights into the association between political ideology and HPV awareness among adults in the United States. They provide a foundation for further research and the development of targeted interventions to improve HPV-related knowledge and awareness among different political groups.
In light of study results, it is important to consider incorporating individuals’ political ideologies in interventions aimed at increasing awareness and uptake of the HPV vaccine. Tailoring public health campaigns to specific political affiliations and ideologies may help to improve the effectiveness of such interventions. More so, novel channels to promote HPV vaccine awareness such as through the use of health information technology must be explored.Citation31 In addition, further research is needed to explore the underlying reasons for the differences in awareness of HPV and the HPV vaccine observed among political groups. Understanding the factors contributing to these differences may help to develop more targeted and effective interventions. Factors that could be explored in future research include differences in exposure to health information, attitudes toward vaccination and government health initiatives, and beliefs about the safety and efficacy of vaccines.Citation22,Citation32,Citation33
Overall, our study adds to a growing body of evidence that demonstrates the impact of politics on important public health issues. It crucial for political figures to take more responsibility in ensuring that public health issues are not politicized.Citation34 More so, it is critical for government health agencies to develop effective public health interventions that can increase awareness and uptake of HPV vaccination in the US. This is particularly important given the significant burden of HPV-associated cancers and the availability of a safe and effective vaccine.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- Centers for Disease Control and Prevention. Cancers associated with human papillomavirus, United States—2015–2019. USCS Data Brief, no 32. Atlanta (GA): Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022.
- Chido-Amajuoyi OG, Talluri R, Wonodi C, Shete S. Trends in HPV vaccination initiation and completion within ages 9–12 years: 2008–2018. Pediatrics. 2021;147(6). doi:10.1542/peds.2020-012765.
- Chido-Amajuoyi OG, Jackson I, Yu R, Shete S. Declining awareness of HPV and HPV vaccine within the general US population. Human Vaccines Immunother. 2020;17:420–7. doi:10.1080/21645515.2020.1783952.
- Navarro V, Muntaner C, Borrell C, Benach J, Quiroga Á, Rodríguez-Sanz M, Vergés N, Pasarín MI. Politics and health outcomes. Lancet. 2006;368(9540):1033–7. doi:10.1016/S0140-6736(06)69341-0.
- Neelon B, Mutiso F, Mueller NT, Pearce JL, Benjamin-Neelon SE. Associations between governor political affiliation and COVID-19 cases, deaths, and testing in the US. Am J Prev Med. 2021;61(1):115–19. doi:10.1016/j.amepre.2021.01.034.
- Shete SS, Yu R, Shete S. Political ideology and the support or opposition to United States tobacco control policies. JAMA Netw Open. 2021;4(9):e2125385. doi:10.1001/jamanetworkopen.2021.25385.
- Baumgaertner B, Carlisle JE, Justwan F, Rabinowitz M. The influence of political ideology and trust on willingness to vaccinate. PLoS One. 2018;13(1):e0191728. doi:10.1371/journal.pone.0191728.
- Manganello JA, Chiang SC, Cowlin H, Kearney MD, Massey PM. HPV and COVID-19 vaccines: social media use, confidence, and intentions among parents living in different community types in the United States. J Behav Med. 2023;46(1–2):212–28. doi:10.1007/s10865-022-00316-3.
- Gollust SE, Attanasio L, Dempsey A, Benson AM, Fowler EF. Political and news media factors shaping public awareness of the HPV vaccine. Womens Health Issues. 2013;23(3):e143–e51. doi:10.1016/j.whi.2013.02.001.
- Gerend MA, Shepherd JE. Correlates of HPV knowledge in the era of HPV vaccination: a study of unvaccinated young adult women. Women Health. 2011;51(1):25–40. doi:10.1080/03630242.2011.540744.
- Chido-Amajuoyi OG, Pande M, Agbajogu C, Yu RK, Cunningham S, Shete S. HPV vaccination uptake, hesitancy, and refusal: observations of health-care professionals during the COVID-19 pandemic. JNCI Cancer Spectr. 2022;6(4):kac053. doi:10.1093/jncics/pkac053.
- Troiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public Health. 2021;194:245–51. doi:10.1016/j.puhe.2021.02.025.
- Gollust SE, LoRusso SM, Nagler RH, Fowler EF. Understanding the role of the news media in HPV vaccine uptake in the United States: synthesis and commentary. Hum Vaccin Immunother. 2016;12(6):1430–4. doi:10.1080/21645515.2015.1109169.
- Daley EM, Vamos CA, Thompson EL, Zimet GD, Rosberger Z, Merrell L, Kline NS. The feminization of HPV: how science, politics, economics and gender norms shaped U.S. HPV vaccine implementation. Papillomavirus Res. 2017;3:142–8. doi:10.1016/j.pvr.2017.04.004.
- Udesky L. Push to mandate HPV vaccine triggers backlash in USA. Lancet. 2007;369(9566):979–80. doi:10.1016/S0140-6736(07)60475-9.
- Franco M, Mazzucca S, Padek M, Brownson RC. Going beyond the individual: how state-level characteristics relate to HPV vaccine rates in the United States. BMC Public Health. 2019;19(1):1–9. doi:10.1186/s12889-019-6566-y.
- Bernstein S, North A, Schwartz J, Niccolai LM. State-level voting patterns and adolescent vaccination coverage in the United States, 2014. Am J Public Health. 2016;106(10):1879–81. doi:10.2105/AJPH.2016.303381.
- Amboree TL, Montealegre JR, Wermuth PP, Mgbere O, Fujimoto K, Darkoh C. Awareness of human papillomavirus and reported human papillomavirus vaccine uptake in a high-risk population. Prev Med Rep. 2022;28:101853. doi:10.1016/j.pmedr.2022.101853.
- Pink SL, Chu J, Druckman JN, Rand DG, Willer R. Elite party cues increase vaccination intentions among republicans. Proc Natl Acad Sci USA. 2021;118(32):e2106559118. doi:10.1073/pnas.2106559118.
- Ward JK, Alleaume C, Peretti-Watel P, Peretti-Watel P, Seror V, Cortaredona S, Launay O, Raude J, Verger P, Beck F, et al. The French public’s attitudes to a future COVID-19 vaccine: the politicization of a public health issue. Social Sci Med. 2020;265:113414. doi:10.1016/j.socscimed.2020.113414.
- Wollebæk D, Fladmoe A, Steen‐Johnsen K, Ihlen Ø. Right‐wing ideological constraint and vaccine refusal: the case of the COVID‐19 vaccine in Norway. Scand Pol Stud. 2022;45(2):253–78. doi:10.1111/1467-9477.12224.
- Smith DT, Attwell K, Evers U. Support for a COVID-19 vaccine mandate in the face of safety concerns and political affiliations: an Australian study. Politics. 2022;42(4):480–91. doi:10.1177/02633957211009066.
- Abiola SE, Colgrove J, Mello MM. The politics of HPV vaccination policy formation in the United States. J Health Polit Policy Law. 2013;38(4):645–81. doi:10.1215/03616878-2208567.
- Bednarczyk RA. Addressing HPV vaccine myths: practical information for healthcare providers. Hum Vaccin Immunother. 2019;15(7–8):1628–38. doi:10.1080/21645515.2019.1565267.
- Zimet GD, Rosberger Z, Fisher WA, Perez S, Stupiansky NW. Beliefs, behaviors and HPV vaccine: correcting the myths and the misinformation. Prev Med. 2013;57(5):414–8. doi:10.1016/j.ypmed.2013.05.013.
- Hersh ED, Goldenberg MN. Democratic and republican physicians provide different care on politicized health issues. Proc Natl Acad Sci USA. 2016;113(42):11811–16. doi:10.1073/pnas.1606609113.
- Mello MM, Abiola S, Colgrove J. Pharmaceutical companies’ role in state vaccination policymaking: the case of human papillomavirus vaccination. Am J Public Health. 2012;102(5):893–8. doi:10.2105/AJPH.2011.300576.
- Hughes J, Cates JR, Liddon N, Smith JS, Gottlieb SL, Brewer NT. Disparities in how parents are learning about the human papillomavirus vaccine. Cancer Epidemiol Biomarkers Prev. 2009;18(2):363–72. doi:10.1158/1055-9965.EPI-08-0418.
- Ellis EM, Ferrer RA, Klein WM. Factors beyond lack of knowledge that predict “I don’t know” responses to surveys that assess HPV knowledge. J Health Commun. 2018;23(10–11):967–76. doi:10.1080/10810730.2018.1554729.
- Cantor D, Coa K, Crystal-Mansour S, Davis T, Dipko S, Sigman R. Health information national trends survey (HINTS) 2007. Rockville (MD): Westat; 2009.
- Onyeaka HK, Muoghalu C, Deary EC, Ajayi KV, Kyeremeh E, Dosunmu TG, Jawla M, Onaku E, Nwani SP, Asante KO, et al. The role of health information technology in improving awareness of human papillomavirus and human papillomavirus vaccine among US adults. Telemed E-Health. 2022;29:886–95. doi:10.1089/tmj.2022.0381.
- Chido-Amajuoyi OG, Talluri R, Shete SS, Shete S. Safety concerns or adverse effects as the main reason for human papillomavirus vaccine refusal: national immunization Survey–Teen, 2008 to 2019. JAMA Pediatr. 2021;175(10):1074. doi:10.1001/jamapediatrics.2021.1585.
- Chido-Amajuoyi OG, Talluri R, Jackson I, Shete SS, Domgue JF, Shete S. The influence of parent–child gender on intentions to refuse HPV vaccination due to safety concerns/side effects, national immunization Survey–Teen, 2010–2019. Hum Vaccin Immunother. 2022;18(5):2086762. doi:10.1080/21645515.2022.2086762.
- Sharfstein JM, Callaghan T, Carpiano RM, Sgaier SK, Brewer NT, Galvani AP, Lakshmanan R, McFadden SM, Reiss DR, Salmon DA, et al. Uncoupling vaccination from politics: a call to action. Lancet. 2021;398(10307):1211–12. doi:10.1016/S0140-6736(21)02099-7.