Topics associated with conflict in print news coverage of the HPV vaccine during 2005 to 2009

Abstract

HPV vaccines represent a significant advancement for cancer prevention, but vaccination against a sexually transmitted infection and possible vaccine mandates have created considerable negative publicity. We sought to understand media portrayal of vaccine-related controversy, and potential influences on attitudes and vaccine acceptance. We analyzed characteristics of media coverage of the HPV vaccine in 13 US newspapers between June 2005-May 2009, as well as relationships between conflict and pro-vaccine tone and specific story characteristics. The four-year timeframe was selected to capture coverage during the development of the vaccine, the period immediately pre- and post-approval, and the time of widespread recommendation and initial uptake. This allowed the exploration of a range of issues and provided an understanding of how coverage changed over time. Analysis included 447 news stories and opinion pieces, the majority of which were published in 2007. Most articles were positive (pro-vaccine) in tone, prompted by research/scientific advancement or legislative activities. We deemed 66% of all stories conflict-containing. Fewer articles from 2005–2006 and 2008–2009 contained conflict than those from 2007, suggesting a peak period of concern, followed by gradual acceptance of the HPV vaccine. Legislative activities and content related to sexual activity were sources of conflict in HPV vaccine media messages. Health communication strategies can be improved by understanding and addressing potential sources of conflict in news coverage of public health initiatives.

Keywords:

• health communication
• HPV vaccine
• news media
• conflict

Abbreviations:

• HPV, Human Papillomavirus
• US, United States
• FDA, Food and Drug Administration
• STI, sexually transmitted infection
• OR, odds ratio
• CI, confidence interval
• DC, District of Columbia
• E.O., Executive Order
• CDC, Centers for Disease Control and Prevention

Background

Media-worthy events, such as the development and approval of a vaccine to prevent HPV infection, create an opportunity for communicating public health messages. The media play a role in agenda-setting by increasing the salience of reported topics.^1,2 Given the media's potential influence, it is important to examine how the media communicates public health information. The HPV vaccine Gardasil, first approved by the US FDA in 2006, is a valuable advancement in health technology, but in order for the public to make informed decisions about vaccination, it is critical to promote understanding of the nature of HPV infection and its link to cervical cancer, as well as cervical cancer screening options. Although HPV is the second most common STI in the US, most HPV infections resolve without treatment and do not go on to cause cervical cancer.³ Additionally, screening to detect precancerous cells and early treatment can prevent progression to cervical cancer.

Public knowledge about HPV and its link to cervical cancer at the time of vaccine approval was low.⁴ Additionally, media messages prior to and surrounding FDA approval often failed to communicate the complex relationship between HPV infection and cervical cancer.^5-8 However, exposure to health-related news media was associated with greater HPV knowledge.⁸ In the 3 months after approval, messages in online news stories reflected common social concerns such as vaccine affordability (49%), an increase in sexual risk factors (38%), and mandatory school vaccination (32%).⁷ The majority of print news coverage in the 19 months after FDA approval (June 2006-December 2007) continued to lack detailed information about HPV and the vaccine, and about 30% of the 547 articles analyzed mentioned sexual morality concerns tied to vaccination.⁹

Sexual transmission of HPV and the early age recommended for vaccination (11 to 12 years) have led to controversy-filled discussions about vaccination, especially state-mandated vaccination.^10,11 Most school mandates exist to prevent diseases spread through casual rather than intimate contact. Yet, in 2006 and 2007 more than 25 states proposed school-based HPV vaccine mandates for female students.¹² Another relevant factor is vaccine cost, and potential inequities in access. At approximately $360 per person, the HPV vaccine is one of the most expensive vaccines, and at a population level, translating into billions of dollars to vaccinate all school-age females in the US.¹³

Previous research on HPV vaccine media messages has not specifically examined topics related to conflict or controversy. Research has shown that media coverage of controversial topics can raise awareness of an issue, but also create public uncertainty.^14,15 Controversial media messages about vaccines can erode parents’ overall trust in immunization, leading to declines in vaccine acceptance and uptake.^16-18 Examining topics related to conflict might provide insight as to how public health advancements can be more effectively communicated through the media to increase public awareness and acceptance.

This study investigated media messages about the HPV vaccine over a 4 y timeframe, during which Gardasil was the only FDA-approved HPV vaccine (GlaxoSmithKline's Cervarix was approved in October, 2009).¹⁹ We focused on 2 specific research questions: what were the characteristics of HPV vaccine media messages, and what topics or characteristics of messages were tied to controversy and conflict? This analysis builds on previously published analyses with subsets of these data, focusing on newspapers in mandate jurisdictions²⁰and adolescent sexuality.²¹

Results

An initial capture of 534 articles yielded 447 articles meeting criteria for analyses. Across the 13 newspapers, HPV-related coverage peaked in 2007 (Table 1).

Table 1. Newspaper articles discussing HPV vaccination in 2005–2009, by paper, type of article and article location (N = 447)

			Year of Publication
	Total N = 447	%	2005 n = 28	2006 n = 98	2007 n = 249	2008 n = 63	2009 n = 9
Paper (by circulation)^+			# of articles per year
USA Today	18	4	2	5	7	4	0
The Wall Street Journal	35	8	3	11	14	6	1
The New York Times	52	12	3	10	28	10	1
Los Angeles Times	16	4	0	4	7	3	2
Daily News (NY)	10	2	2	3	5	0	0
The New York Post	9	2	1	3	4	1	0
The Washington Post	67	15	4	16	41	5	1
Chicago Tribune	50	11	6	12	24	8	0
The Houston Chronicle	62	14	2	7	44	9	0
The Arizona Republic	41	9	0	9	26	5	1
Regional Papers
The Virginia Pilot	29	6	1	2	18	8	0
The Richmond Times Dispatch	11	2	0	3	7	1	0
The Baltimore Sun	47	11	4	13	24	3	3
Type of article
News article	335	75	23	77	174	53	8
Opinion/editorial	112	25	5	21	75	10	1
Article location
Front page (of section/paper)	116	26	6	31	69	7	3
Other location	331	74	22	67	180	56	6

Common topics (Table 2)

The most frequent main topic was HPV/vaccine/cancer characteristics (64% of stories). Stories commonly mentioned: age of vaccination (73%), virus spread through sexual contact (63%), protection against specific HPV types (57%), populations other than young females are affected (52%), including adult women (42%) and males (20%). Many stories also discussed STIs (42%), morbidity/mortality of cervical cancer (41%) and vaccination schedules (3 shot series) (40%). Barriers to vaccination were less commonly mentioned: cost/cost-effectiveness (36%), unknowns surrounding vaccination (22%), newness (21%), safety (20%), possible side effects (17%), and duration of protection (10%). Additionally, less than a third of articles discussed risk and prevalence of HPV (32%) and fewer mentioned HPV may clear without treatment (16%).

Fifty-five percent of stories focused on government/state activities. The most common variables were FDA approval/recommendations (58%) and vaccine mandates (53%). Approximately one-quarter of the stories focused on stakeholder interests, and one-quarter focused on social reactions to the vaccine. Pharmaceutical involvement was often mentioned as a stakeholder interest (48%). Under the social reactions topic, articles sometimes mentioned vaccine resistance/uneasiness (33%), implied approval of sexual activity (26%), and controversy (21%).

Health behaviors and ethical issues were the least common main topics, appearing in 11% and 8% of stories respectively. Sexual activity (as an individual behavior) was the most common variable in the health behavior topic, cited in 44% of stories. Promiscuity was mentioned in 15% of stories, followed by abstinence (14%), early initiation of sexual activity (10%), and condom use (7%). The most common ethical issues mentioned were parental autonomy/individual rights (19%) and health disparities (13%).

The majority of articles were determined to have 2 main topics, and thus 847 topics were identified in the 447 articles. Frequency of 3 topics varied significantly by year (2007 vs. 2005–2006, 2008–2009): ethical issues and government activities were more common in 2007, while the characteristics topic was less common.

Events (Table 2)

The most common events responsible for coverage (sometimes known as ‘news pegs’) were research/scientific advancement (27%), legislative activities (27%), and government action (20%). Events prompting coverage varied over time. Over half of articles published in 2005 and 2008 responded to research/scientific advancements. The majority of 2006 articles (52 of 98, or 53%) resulted from government action, namely FDA approval of the vaccine. In 2007, legislative activity most commonly generated coverage (111of 249 articles, or 45%).

Cited sources (Table 3)

Table 3 displays the frequency of sources quoted in this sample of articles. Medical providers or researchers/professors were the most frequently cited source every year except 2007, when state/local government representatives were more frequently called upon for commentary. Nineteen percent of sources were coded in multiple categories, such as a doctor who also conducted research.

Table 2. Characteristics of newspaper articles discussing HPV vaccination in 2005–2009, by article topic, tone, and event, and conflict (N = 447)

			Year of Publication
	Total N = 447	%	2005 n = 28	2006 n = 98	2007 n = 249	2008 n = 63	2009 n = 9	X^2*
Article topic (up to 2/article)			% of articles by year
HPV/Vaccine Characteristics	287	64	71	79	50	90	89	<0.001
Government/State Activities	246	55	25	59	61	43	11	0.002
Social Influences/Reactions/Attitudes	117	26	46	18	30	14	33	0.08
Stakeholders	112	25	32	19	28	19	22	0.23
Behaviors	49	11	18	14	8	11	22	0.14
Ethical Issues	36	8	0	2	11	10	0	0.005
Tone (1/article)								<0.001
Positive (e.g., vaccine benefits)	206	46	61	75	35	38	55
Mixed	162	36	32	22	41	41	33
Negative (e.g., risks; barriers)	44	10	0	0	15	11	0
Neutral; none of the above	35	8	7	3	9	10	11
Event prompting story (1/article)								<0.01
Research/scientific advancement	121	27	64	21	17	57	45
Legislative activities	120	27	0	5	45	6	0
Government action/ Regulatory body	89	20	7	53	10	16	11
Other stakeholder action	55	12	14	8	14	11	0
Other event	25	6	7	5	6	3	11
No event evident	21	5	4	4	4	53	33
Response to op/ed	16	3	1	4	10	1	0
Conflict present	296	66	57	56	73	59	56	0.001

⁺Top 10 newspapers listed in order of circulation (BurrellesLuce, 2009)

*p-values reported for Pearson X² test for the variable by time where 2007 was the reference year compared to 2005–2006 and 2008–2009.

Table 3. Sources quoted in newspaper articles discussing HPV vaccination in 2005–2009, (N = 447)

Source quoted	N	%
Professional stakeholders
Provider/medical association	152	34
Researcher/professor	139	31
Advocacy/non-profit group	119	27
Health/cancer focus	53	12
Social conservative/parents’ rights focus	46	10
Other (e.g., political)	20	4
Pharmaceutical industry	109	24
State/local government	108	24
Federal government (e.g., CDC)	81	18
Lawyer	9	2
Financial/stock analyst	9	2
Insurance company	8	2
Lay stakeholders
Parent	59	13
Author of previous article/op ed	32	7
Vaccine consumer (potential or actual)	19	4
Cancer patient/survivor	16	4
Other source (e.g., advertisement, teacher, radio show)	11	2
Multiple roles (for one source) are coded	84	19
No source cited	60	13

Tone and conflict (Tables 2 and 4)

Taken as a whole, the majority of stories were either positive (46%) or mixed (36%) in tone, reflecting an overall pro-vaccine perspective to most of the stories. Only 10% of stories were negative and all negative coverage occurred in 2007 and 2008. A chi-square test indicated significant differences in article tone over time (p < 0.001) (Table 2).

In bivariate analyses of tone (mixed/negative vs. positive) and topic (Table 4), tone was significantly less likely to be positive if the topic was ethical issues (OR = 0.45, 95% CI: 0.21–0.95), government/state activities (OR = 0.49, 95% CI: 0.33–0.72), stakeholders (OR = 0.62, 95% CI: 0.40–0.98), or social reactions (OR = 0.44, 95% CI: 0.28–0.69). Tone was significantly more likely to be positive than mixed/negative if the topic was characteristics (OR = 4.39, 95% CI: 2.83–6.78) or health behaviors (OR = 3.90, 95% CI: 1.86–8.07).

Table 4. Odds of the presence of conflict and positive tone in news articles discussing HPV vaccination by topic, year, and article characteristics

	N	Conflict		Positive Tone
Topic		OR	95% CI	OR	95% CI
HPV/cervical cancer/vaccine characteristics	287	0.25**	0.16–0.41	4.39**	2.83–6.78
Government/state activities	246	2.91**	1.94–4.37	0.49**	0.33–0.72
Social influences/reactions/attitudes	117	4.37**	2.47–7.74	0.44**	0.28–0.69
Stakeholders	112	0.76	0.49–1.19	0.62*	0.40–0.98
Behaviors	49	0.71	0.39–1.31	3.90**	1.86–8.07
Ethical Issues	36	2.23	0.96–5.23	0.45*	0.21–0.95
Year
2007	249	1.00	(reference)	1.00	(reference)
2005–2006	126	0.47**	0.30–0.73	4.64**	2.85–7.56
2008–2009	72	0.50*	0.29–0.87	1.29	0.74–2.25
Type of article
News article	335	0.42**	0.25–0.70	1.22	0.79–1.90
Opinion/editorial	112	1.00	(reference)	1.00	(reference)
Article location
Front page (of section/paper)	116	1.59*	1.09–2.31	0.76	0.54–1.06
Other location	331	1.00	(reference)	1.00	(reference)

**p < 0.01.

*p < 0.05.

Overall, 66% of stories contained conflict between stakeholder groups (Table 2). By event, articles prompted by legislative activities were over 4 times more likely to contain conflict (OR: 4.60, 95% CI: 2.58–8.10). In bivariate analyses (Table 4), stories focusing on vaccine characteristics were significantly less likely to contain conflict (OR: 0.25, 95% CI: 0.16–0.40), while government/state activities (OR: 2.91, 95% CI: 1.94–4.37) and social reactions (OR: 4.37, 95% CI: 2.47–7.74) were significantly more likely to contain conflict. Articles published in 2005–2006 (OR: 0.47, 95% CI: 0.30–0.73) and 2008–2009 (OR: 0.50, 95% CI: 0.29–0.87) were significantly less likely to contain conflict compared to 2007 (Table 4).

Sexuality and conflict (Table 5)

Despite the relative infrequency of behavior as a main topic, sexual activity was commonly included in stories focused on issues (44% of stories). It was more common for messages to mention sexual activity in general than more specific aspects like promiscuity (15%), abstinence (14%), early initiation of sexual activity (10%), and condom use (7%). Concerns that vaccination would imply approval of sexual activity among girls was mentioned in 26% of stories. In bivariate analysis, all sexual behavior-related variables except condom use were significantly positively associated with conflict.

Legislation and conflict (Table 5)

The most commonly mentioned variables under the government/state activities topic were discussions of federal approval/vaccine recommendations (58% of articles) and vaccine mandates (53%). Most messages involving state/local government activities were significantly related to conflict in bivariate analysis. The sub-variables most strongly associated with conflict were discussions of the Texas Governor's E.O. (OR: 28.07; 95% CI: 6.80–115.91); discussions of politics (OR: 16.92; 95% CI: 2.28–125.30); and discussions about vaccine mandates (OR: 12.13; 95% CI: 7.42–19.85). As mentioned above, articles prompted by legislative activities compared to any other event were over 4 times more likely to contain conflict.

Discussion

Compared to earlier HPV media coverage, state actions potentially mandating vaccination had a sizable impact on print news, evidenced by heavy coverage of legislative activities. While characteristics about HPV, cervical cancer and the vaccine received extensive coverage, messages evolved as new issues were introduced around vaccine approval and legislation. In 2006, the government/state activities topic became more prevalent, which coincides with FDA approval of the vaccine and the first state legislation introduced to mandate the vaccine for school attendance.¹²

In 2006 Michigan and Ohio proposed school-based mandates for girls entering sixth grade; the bills were not enacted. In 2007, 24 states and DC proposed school-based mandates.¹² Texas became the first state to enact a HPV vaccine mandate by E.O. in February, 2007. The Texas legislature then passed a bill to override the E.O. As reported elsewhere, legislative activity was the most popular event prompting coverage in The Houston Chronicle and government/state activities was the predominant topic.²⁰ Virginia and DC also enacted school-based mandates in 2007 and government/state activity was the predominant topic in The Richmond Times and The Washington Post and the second most common topic in The Virginia Pilot.²⁰ Furthermore, legislative activity was the most common event prompting coverage in The Washington Post and The Richmond Times and the second most common event in The Virginia Pilot.²⁰

Over half of the HPV-related stories in this sample were published in 2007; 61% of these dealt with government/state activities. Most negative stories were also published in 2007. The volume of stories and thematic content demonstrate the importance of legislative activities in media reports of HPV vaccination.

Discussions of government/state activities were significantly more likely to reflect conflict surrounding vaccination and an article was over 5 times more likely to contain conflict if it mentioned legislation. It seems that news producers viewed HPV legislation as a newsworthy topic, as one that would gain public attention. The presence of conflict and controversy over an issue can evoke negative emotions, which may contribute to news attention.²² Work by Mello, Abiola and Colgrove²³ (2012), and our own previous analyses²⁰ further suggest that media coverage of legislation can in turn create backlash against public health efforts, beyond a single vaccine or policy.

Sources in stories about vaccination reflect how the debate is framed, namely who plays a role in defining problems and solutions pertaining to vaccination. Most journalists relied on authoritative sources—medical providers, researchers/professors, and government representatives to frame the issue. The prevalence of local/state government sources signifies the importance of HPV vaccination issues at a local level. The relatively low prevalence of lay sources—parents, vaccine consumers and cancer patients/survivors—places the vaccination debate in the realm of government and professional activities. Overall, a voice coming from the general public seems to be underrepresented.

Our study results are limited to the specific search parameters employed, including time frame and source of news coverage. It is possible that more recent coverage and stories covered in other types of media outlets could yield different results. According to The State of the News Media (2011), 46% of Americans surveyed said they got news online at least 3 times a week, compared to 40% who turned to newspapers.²⁴

However, established, official news media (wire services, traditional print news outlets, national network news, radio) are still both relevant and important. The total audience for combined online and print forms of traditional newspapers remained steady as of 2010.²⁵ One of the ways that traditional media content has retained its relevance is that it continues to serve as the primary source for a great proportion of online news.²⁶ For example, the top 10 circulating newspapers examined in this study are also among the top sources for online news.²⁷ Our analysis of print media therefore also measures stories repeated in internet, TV and popular press channels, and shared by discussions in communities and networks. Print news, as content, is not just text viewed by its readers, but a proxy measure of all news absorbed by the public.

Study results presented here are consistent with previous research on media coverage of the HPV vaccine, but also contain insight as to how coverage changed over a 4 y time frame. A number of studies of HPV media coverage prior to and around the time of vaccine approval primarily analyzed messages about HPV characteristics, the link between HPV and cervical cancer, and vaccine development and found that important health information was often missing.^5-9 Characteristics of HPV/the HPV vaccine/cervical cancer was the most common topic in this sample of articles, and messages continued to provide incomplete information about cervical cancer and HPV. For example, an even smaller proportion of articles in this sample, compared to news stories published between 1995–2002, focused on HPV characteristics such as prevalence (32% vs. 50%), transmission (63% vs. 79%), and clearance (16% vs. 26%).⁵

Incomplete information, from a public health standpoint, can misrepresent the vaccine's necessity and fail to communicate the value of cervical cancer screening. The majority of news coverage in the 19 months after FDA approval (June 2006-December 2007) continued to lack detailed information about HPV and the vaccine, and about 30% of the 547 articles analyzed mentioned sexual morality concerns tied to vaccination.⁹

Compared to government/state activities, discussions around HPV-related behaviors were less likely to contain conflict and were more likely to have a positive tone. Previous studies have found that 30–40% of print news stories published between 2006 and 2007 contained sexual activity concerns tied to vaccination.^9,28,29 We found in these analyses that sexual activity was discussed in 44% of stories and over a quarter of stories specifically discussed concerns that vaccinating young girls could imply approval of sexual activity, possibly over-representing the prevalence of this view. In a review of 28 studies, published between 1995 and January 2007, assessing vaccine acceptability, only 6% to 12% of parents were concerned the vaccine would promote sexual behavior.³⁰ A 2008 survey indicated approximately 15% of 325 parents felt the vaccine would promote sex.³¹ Over-representation of sexual activity concerns may be especially problematic since such concerns are highly associated with conflict. When reporting a story, journalists often present opposing viewpoints, but they may fail to qualify how commonly those views are held.³² Quite possibly, media messages created rather than reflected concern over vaccination's role in increasing sexual activity.²¹

This study also examined characteristics of news media messages over time. We found conflict more likely to be present in 2007 compared to other years. Similar to the introduction of other new health technologies, early news reporting tended to reflect enthusiastic responses to, and positive aspects of vaccination.^33,34 As time passes and problems with new technologies emerge, such as side effects or disagreement over health policies, media reports may reflect and promote controversy.³⁵

Media messages published after 2007 were less likely to contain conflict, possibly due to a decline in legislative activities addressing vaccine mandates. Negative media attention and controversy surrounding compulsory HPV vaccination may have discouraged further legislative activities by signaling public disapproval.³⁶ However, HPV vaccine coverage among adolescents increased from 2007 to 2008 (25% to 37%).³⁷

Since the conclusion of this study, a second HPV vaccine, Cervarix was approved for females 13 to 26 y old and Gardasil was approved for males 9 to 26 y old (both in October 2009).¹⁹ Future research might explore possible differences in conflict and controversy reflected in media coverage around Gardasil's approval for females in 2006 to that of males in 2009 as well as to that of Cervarix's approval for females in 2009.

Future research could also expand understanding of the HPV media environment, including television, popular magazines, and advertising, as well as media targeted to specific groups such as ethnic minorities and pre-teen and teenage women. As well, research investigating audience perception of HPV vaccine messages, including those portraying controversy, could inform public health communication efforts to improve HPV prevention strategies and increase uptake.

Method

The LexisNexis, NewsBank, and ProQuest databases and the azcentral.com archives were used to search the top 10 circulating US newspapers²⁶ and 3 regional newspapers, for articles published in a 4y window (6/1/2005–5/31/2009). Regional papers from Maryland and Virginia were selected to add local perspectives from states considering vaccine mandates during this period. The four year timeframe was purposefully selected to capture coverage during the development of the vaccine, the period immediately pre- and post-approval, and the time of widespread recommendation and initial uptake. This allowed the exploration of a range of issues and provided an understanding of how coverage changed over time. A longer window can also help to reduce potential bias from an analysis of coverage during a short time period, which may be dominated by a particular event.

Search terms included “HPV” or “cervical cancer” (in headline/lead paragraph) and “vaccine” (anywhere in text). The term “HPV” was more inclusive than “human papillomavirus.” Testing common misspellings (e.g. “human papilloma virus” and “human pappilloma virus”) yielded an additional 7 articles. We observed that the vaccine name, Gardasil, was not used without the broader terms “HPV” and/or “vaccine” and it was not used before its approval in 2006, thus it was not retained as a search term. Articles from the initial capture were retained for analysis if they met inclusion criteria of one or more HPV vaccine mention(s) plus a mention of cervical cancer, cancer screening, HPV vaccination, legislation, or sexually transmitted infections. Articles were excluded if they contained only minor mention of the vaccine and focused mostly on other topics (e.g., development of a HIV or breast cancer vaccine; corporate or financial summary).

We developed a structured coding methodology to capture both manifest and latent content, drawing on both explicit use of terms and phrases (manifest content), as well as content identified through interpretation of the meaning of text (latent content). Coding categories were developed through an iterative, grounded theory process, in which the articles were discussed and used to draw lists of key terms and concepts, which were then grouped into categories and built into key topics for structured coding.³⁸

Six main topic areas emerged: ethical issues (e.g. autonomy, girls-only mandate), HPV/vaccine/cervical cancer characteristics (e.g., incidence, efficacy, morbidity), government/state activities (e.g. FDA approval, legislation), health behaviors (including sexual, e.g., abstinence, condom use, promiscuity, as well as use of health care and screening), stakeholder actions/interests (e.g., insurance companies, vaccine manufacturers, physicians), and social reactions/attitudes/influences (e.g., parental opinions, physician recommendation). We then developed specific codes for content within each topic, with a total of 91 unique variables captured.

Each article could receive either one or 2 main topic codes, identified by the title and focus of the story. We also captured additional story content descriptors—event prompting story, sources quoted, story tone (positive, negative, mixed, or neutral toward the HPV vaccine), and conflict (present or not), as well as characteristics of the articles themselves, including placement of story, word length, and news versus opinion/editorial. The conflict code was assigned to articles which discussed competing viewpoints, and described tension due to lack of consensus.

Coding reliability was established in several ways. Refinement of the coding schema occurred through 4 rounds of preliminary coding. The research team independently coded 10 sample articles in each round to determine if and how well the coding options could be applied, after which all articles were discussed and discrepancies identified. Explicit coding rules were established during this phase to ensure consistency during the coding process. Two team members then each coded half of the remaining articles. Coding questions were flagged and resolved in team discussions to reach consensus.

We assessed inter-coder reliability for 3 key constructs: tone, the presence of conflict, and topic. We double coded 5% of articles (n = 22) and calculated kappa, which adjusts the observed rate of agreement for agreement based on chance. The reliability standard was kappa ≥ 0.60, which indicates substantial agreement between coders.³⁸ For tone, conflict, and topic, kappa was 0.66, 0.69, and 0.86 respectively.

We examined descriptive frequencies for all variables of interest, overall and by year and sources cited (Tables 1–3). Bivariate analyses include odds ratios for relationships between the presence of conflict and vaccine-related position or tone by other article characteristics (Table 4). In addition, in order to further understand the sources of conflict, we examined the relationship between specific variables related to sexuality and government/state activity and the presence of conflict (Table 5). Finally, to illustrate the relationships in Table 5, we provide examples of text from conflict-containing articles (Table 6). Analyses were conducted using STATA, version 9.0.

Table 5. Odds of the presence of conflict in news articles discussing HPV vaccination by sexual behavior-related content and government/state activities

	N	OR	95% CI
Sexual behavior variables
Sexual activity	196	2.35**	1.55–3.55
Abstinence	61	4.60**	2.03–10.36
Early initiation of sexual activity	43	5.58**	1.95–15.91
Condom use	31	0.69	0.33–1.44
Promiscuity	69	2.48**	1.31–4.69
Implied approval of sexual activity	115	17.27**	6.87–43.42
Government/state activity variables
Legislation	160	5.48**	3.28–9.17
Executive Order	83	28.07**	6.80–115.91
Opt-out	89	5.13**	2.57–10.25
Politics	31	16.92**	2.28–125.30
Lawsuits	20	2.10	0.69–6.40
Federal approval/recommendations	260	0.88	0.59–1.31
VFC program	31	3.69*	1.27–10.74
Low-income/government funding in general	81	3.17**	1.69–5.94
Vaccine requirement/mandate	238	12.13**	7.42–19.85
Abstinence only programs	14	3.15	0.70–14.25
Education/sex education	39	2.49*	1.07–5.79
Vaccine adverse events reporting	15	always associated with conflict (OR cannot be estimated)
Role of school/effect on schools	160	7.37**	4.23–12.82
cost to government/state (incl. budget)	54	2.16*	1.08–4.33

**p < 0.01.

*p < 0.05.

Table 6. Illustrative examples of text containing conflict

Title	Source, Article Type, Date	Coded Variables	Text
Making health a priority; Benefits of HPV vaccine for young girls outweigh cost and moral concerns.	The Houston Chronicle, opinion, 1/23/2007	Early initiation of sexual activity	“Unfortunately, we live in a world where kids grow up way too fast. Those against this vaccination believe that it will somehow encourage young girls to become sexually active at an earlier age. What they ignore is that everything these days encourages early sexual behavior.”^39
Vaccine for Girls Raises Thorny Issues; Parents Weigh Anti-Cancer Benefits Against Concerns About Cost and Lost Innocence.	The Washington Post, news, 11/7/2006	Mandates, safety, promiscuity, parents’ rights	“Proponents of the vaccine have been advocating mandatory vaccination of girls, sparking an intense nationwide debate. Opponents say that the vaccine may encourage sexual activity and that its safety and long-term effectiveness are not clear because it is so new. They argue that the decision should be made by parents individually.”^40
Vaccine for Girls Raises Thorny Issues; Parents Weigh Anti-Cancer Benefits Against Concerns About Cost and Lost Innocence	The Washington Post, news, 11/7/2006	Doctor recommendation, abstinence, sexual activity, role of men/boys	“So some pediatricians are advising parents who are confident their daughters will be abstinent until they are older, perhaps even until marriage, to wait… . Supporters argue that parents have no way of really knowing when their daughters will become sexually active or whether they may be sexually assaulted. And even if they remain abstinent until marriage, their husbands may be infected.” ^40
Perry muscle flexing falls flat; Controversial executive orders spur lawmakers to exercise their own authority	The Houston Chronicle, news, 2/25/2007	Executive Order, mandate, politics	“The next day, a House committee approved a bill to overturn Perry's executive mandate that all sixth-grade girls be vaccinated against a sexually transmitted virus that causes most cervical cancers. ‘On the vaccine, the Legislature was relatively insulted about that,’ said House Appropriations Chairman Warren Chisum, a Republican who has been allied with Perry in the past. ‘They just felt it was important to exercise their authority as a Legislature.’"^41
Early Shots at STD - Vaccine To Schools	The New York Post, news, 3/30/2007	VFC program, low-income funding, Role of/effect on schools, lobbying, promiscuity	"The federal Vaccines for Children program provides free vaccines to girls age 9 through 18 who are on Medicaid or have inadequate insurance. State law requires that other girls get coverage through their private insurers. Health officials were quick to note that parental consent is required to give the vaccine. Merck, the manufacturer of Gardasil, has backed state laws to make it easier to distribute the HPV vaccine in schools. But it recently backed off its lobbying campaign following criticism that such laws would encourage promiscuity among youths.” ^42
Drugmaker Helps Push Mandatory HPV Shots	The Washington Post, news, 2/11/2007	Mandate, politics, stakeholders, parents’ rights, promiscuity	“In the case of mandating the HPV vaccine, there are good political reasons for nonprofit health groups to stay out of the debate, which has engaged critics who believe requiring a vaccine against a sexually transmitted disease would undermine parental authority and also encourage promiscuity (Gardner, 2007).” ^43
Moves to Vaccinate Girls For Cervical Cancer Draw Fire; As Merck Lobbies States To Require Shots, Some Fret Over Side Effects, Morals	The Wall Street Journal, news, 2/7/2007	Legislation, opt-out, mandate, role of/effect on schools	“Bills being drafted in some 20 US states that would make a cervical-cancer vaccine mandatory for preteen girls are sparking a backlash among parents and consumer advocates… . Many of the state bills contain opt-out clauses, but a few don't. The bill pending in Florida would bar students ages 11 or 12 from being admitted to public or private school in the state unless they can provide proof that they have been vaccinated or that their parents opted them out after receiving information about cervical cancer and the vaccine.” ^44
Utah Vaccine Campaign to Be Funded Privately	Los Angeles Times, news, 4/4/2007	Legislation, cost to government/state, education, low-income/government funding, promiscuity	“The bill's backers had high hopes. They proposed that Utah spend $1 million for a public education campaign about the risks of cervical cancer and a new vaccine that can prevent it, as well as fund vaccinations for poor, uninsured patients. But conservatives in the state legislature objected, partly because cervical cancer is spread sexually and they feared that making vaccines available would encourage children to be promiscuous. The program was withdrawn from consideration in early February.” ^45

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

Funding

This research was supported in part by the Richard L Gelb Cancer Prevention Faculty Innovation Award to Dr. Klassen. Dr. Casciotti was also supported by the NCI Cancer Epidemiology, Prevention and Control Institutional Training Program at Johns Hopkins Bloomberg School of Public Health (T32 CA009314), and the Johns Hopkins Carol Eliasberg Martin Scholarship in Cancer Prevention.