Development and Evaluation of a Social Media Health Intervention to Improve Adolescents' Knowledge About and Vaccination Against the Human Papillomavirus

This study describes the formative research, execution, and evaluation of a 3-month social media health intervention conducted in the United States (US) in an effort to improve adolescents' (ages 13-18) knowledge about and vaccination against human papillomavirus (HPV). In addition, the study also assessed whether receiving information about the virus and vaccine could lead to interpersonal discussions with others (most notably, parents and health care providers) as a precursor to vaccination.

HPV vaccine uptake in the US continues to lag well behind those of other adolescent vaccines; only 49.5% of females and 37.5% of males, aged 13 to 17 years, were up-to-date with the HPV vaccination series, as of 2016. Many young people are not vaccinated because of a lack of awareness and/or misconceptions about the virus and vaccine among themselves and/or their parents. There is evidence that adolescents can play a role in the decision-making process. While time is often limited in face-to-face visits, clinicians can continue the conversation with their adolescent patients outside of the clinic by meeting them in online spaces; in the US, 92% of adolescents say they go online every day.

A social marketing approach guided the current study, by gathering insight via formative research that ultimately led to the intervention development and execution. The health belief model (HBM) was employed as a guiding theory. For instance, components of the HBM were used in the development of the focus group moderator guide to ensure full assessment of the adolescents' current knowledge and understanding of the virus and vaccine (i.e., perceived benefits, barriers, severity, susceptibility) to then determine how to best present the most relevant information for the final intervention (i.e., cues to action). A participatory action research framework - centred around youth advisory board meetings - enabled participants to guide the interpretation and focus to ensure actions taken were reflective of their needs and interests. Based on the results from the formative focus groups with adolescents (N = 38), the researchers developed and conducted a pretest/posttest evaluation of the social media health intervention for adolescents who had not completed the HPV vaccine series (N = 108).

Specifically, the final social media health intervention was developed based on the feedback that adolescents would be willing to receive health information via social media if: the source was considered credible and relevant, the information provided was considered interesting (and not just about one health topic), and their privacy online was protected. A private Facebook page was created called "About Your Health" and was maintained by local (i.e., the state in which the participants lived) health care providers. To ensure protection of privacy, which was articulated by adolescents as simply appearing in their news feed and not on their personal page, a new health fact was posted by the Facebook page (and would therefore appear in news feed of those who eventually participated in the intervention) twice a week. A total of 24 health facts were posted to the Facebook page throughout a 3-month period and included relevant images and links to credible websites for more information about each topic. Since participants requested that the information provided not only be about one health topic, only 11 of the 24 facts were specifically about HPV and/or the HPV vaccine.

Each fact addressed a modifying factor proposed by the HBM and most relevant to the information focus group participants were interested in learning, such as virus susceptibility (e.g., "Anyone can get HPV if they engage in sexual contact with someone else"), virus severity (e.g., "HPV can eventually lead to genital warts and cancer in both girls and boys"), vaccine benefits (e.g., "It is best for teens to receive the HPV vaccine before they engage in sexual contact, but the vaccine may still prevent HPV at any time"), vaccine barriers (e.g., "The HPV vaccine is constantly being checked for safety by public health organizations"), and self-efficacy (e.g., "There is no cure for HPV, but you can help prevent it by getting the HPV vaccine"). The HPV-related facts (i.e., call to action) were created based on the formative research feedback and the guiding presumptions of the HBM that indicate individuals will take a health-related action (i.e., vaccination), if they perceive the action as worthwhile to avoid a health condition (i.e., perceived susceptibility and severity of transmitting HPV) and beneficial (i.e., perceived benefits and barriers of getting vaccinated).

Eighty-two participants were randomly assigned to the intervention group, and 26 were assigned to the control group. Broadly, results revealed that:

• Adolescents who fully engaged with the intervention improved in their knowledge compared with a control group. It was found that the adolescent must fully engage (e.g., receive notifications) and receive all relevant content for significant knowledge gain to occur. Therefore, providing health information via social media channels may only be a strategy helpful to a specific group of adolescents, namely, adolescents who are motivated to improve their sexual health and receive health information via their social media feeds.
• In some cases, engaging in the intervention also led to interpersonal discussions with others (e.g., parents, doctors) about what they learned. Notably, participants who had interpersonal discussions as a result of the intervention were much higher on knowledge gain in general than other adolescents in the study. This finding may suggest that there are unique motivational factors of adolescents willing to engage with social media health interventions, such that adolescents who already have a base level of knowledge or interest about a topic may be more willing to engage and share that information with others.
• A significant increase in HPV vaccination, however, did not occur as a result of the intervention. These findings suggest that the strategic approach of providing informative health facts via a commonly used media channel (i.e., Facebook) has the potential to be an educational strategy for improving adolescents' HPV knowledge but may not be enough on its own to move adolescents toward behaviour change (i.e., HPV vaccination).

The researchers note that:

• Communicating with the adolescent patient via social media is more complicated than simply crafting and sending/posting an engaging message. To appear on an adolescent's social media "news feed" (using Facebook as an example), for example, the adolescent must first "Like" (Facebook) the account and actively engage with the information being posted. Therefore, health care providers must understand the motivations and interests of their adolescent patients to ensure they are creating a platform worthy of appearing in their adolescent patients' news feeds.
• Some content (i.e., sensitive health information) will not be suitable for distribution via personal channels. As HPV is a sexually transmitted infection, open discussion of the vaccine in public spaces could lead to potential stigmatisation. Messages about HPV and the vaccine, therefore, must be provided in places where adolescents can access the information without being directly connected to the message.
• Developing and maintaining these digital relationships can be time-consuming. "Enlisting help from youth staff members or an advisory board of adolescent patients could be a potential strategy to handle development workload and ensure that messages are perceived as interesting, relevant, and worthwhile to adolescents."

In terms of future research:

• While the HBM was used to guide the message development of the current intervention, social cognitive theory may also be an additional theory to consider, such that messages could also focus on relevant social interactions and behaviour modeling (e.g., seeing someone like them getting vaccinated or talking to their doctor).
• Additional research could try to understand what makes some adolescent participants fully engage while others do not. Based on the data available, demographic differences (e.g., gender, age, etc) between the intervention and control groups were not found, and therefore, individual motivations for engagement might be worth exploring in order to determine the type of adolescent most receptive (and, ultimately, to focus on providing messages specific to those adolescents to lead to significant behaviour change).

In conclusion: "Despite the lack of successful behavior change found as a result of this intervention, the interest of some adolescents to engage in social media health interventions reveals potential opportunities for health care providers to engage with at least some of their adolescent patients. Receiving a physician recommendation to get vaccinated remains a key predictor of vaccine uptake, and providers do not always have the time or ability to fully educate their patients in the clinic. They can use social media as a place to further inform adolescents about the decision to get vaccinated."