Television news coverage about cervical cancer: impact on female viewers vulnerability perceptions and fear

Transcription

1 European Journal of Public Health, Vol. 21, No. 3, ß The Author Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi: /eurpub/ckq040 Advance Access published on 26 May Television news coverage about cervical cancer: impact on female viewers vulnerability perceptions and fear Marijke Lemal, Jan Van den Bulck School for Mass Communication Research, Katholieke Universiteit Leuven, Leuven, Belgium Correspondence: Marijke Lemal, Leuven School for Mass Communication Research, Katholieke Universiteit Leuven, Parkstraat 45, Box 3603, 3000 Leuven, Belgium, tel: , fax: , Received 31 August 2009, accepted 16 March 2010 Introduction Background: The objective of this study was to examine the relationship between exposure to television news messages about cervical cancer and women s vulnerability perceptions and fear. Methods: Five-hundred women aged years were randomly recruited to participate in a survey-interview. A standardized questionnaire assessed risk perception, fear of cervical cancer, exposure to cervical cancer messages in television news and a number of potential confounders such as demographics and trait anxiety. Results: Results from multinomial regression analyses showed that women who had been occasionally exposed to cervical cancer messages were two times more likely to be very of getting cervical cancer. Women who had been frequently exposed were three times more likely to be very and three times more likely to be extremely. Women who had been regularly exposure to cervical cancer messages were also three times more likely to perceive a moderate risk and seven times more likely to perceive a large risk of being diagnosed with cervical cancer. Conclusion: These results suggest that television news may be an effective means for health education. Keywords: cervical cancer, fear, human papilloma virus, risk perception, television news... ervical cancer is the second most common cancer for Cyoung women (15 44 years of age) in Europe. Every year women are diagnosed, and of them die from cervical cancer. 1 In September 2006, the European Medicines Agency (EMEA) licensed a vaccine for the prevention of human papilloma virus (HPV), a sexual transmitted virus that is responsible for 70% of all cervical cancer cases. 2 In Belgium, one year after the first vaccine was introduced to the market, the Ministry of Health decided to reimburse vaccination for girls between 12 and 18 years of age. At the same time, public health organizations and GlaxoSmithKline launched awareness campaigns to motivate young women to get vaccinated and to increase their knowledge about the illness. This was followed by a large increase of news media coverage of cervical cancer and HPV. 3 A search of the Belgian digital press archive (Mediargus) 4 showed that there was a 3-fold increase in news stories about cervical cancer during September December 2007 (104 messages), compared to the period of January to April of that same year (35 messages). News messages reported on the nature of the illness, the possibility of vaccination and on personal stories of women who were diagnosed with cervical cancer or those who had successfully prevented it. Research indicates that news media play an important role in disseminating health information. A large scale survey found that 20% of Europeans viewed television as their main source of health information and a further 38% perceived television as an additional source. 5 Further, a recent study of students knowledge, awareness and beliefs about HPV showed that public media, such as television and newspapers, were the most important source of information about the virus: 60% of the respondents had heard about HPV from the media, whereas only 39% had gained information through a health care provider. 6 Given its role in delivering health information, news media may have the potential to educate the public on a variety of health issues. In the context of cervical cancer, longitudinal studies have reported that exposure to news media was related to a dramatic increase in knowledge about HPV. 3,7 However, to our knowledge no study has investigated the relationship between exposure to news media coverage and women s risk perceptions and fear of cervical cancer. While it may be important to increase public knowledge and awareness about cervical cancer or HPV, 8 this may not be sufficient to enhance willingness to undergo screening or vaccination. 9 Socio-cognitive theories of health behaviour (e.g. Health Belief Model, 10 Extended Parallel Process Model 11 ) suggest that risk perception and fear or worry are also important predictors of preventive health actions. A comprehensive review of research examining the role of cancer worry in screening found that worry or fear about cancer led to increased screening intentions and behaviour in most cases. 12 Similarly, a survey study of 1348 Italian female adolescents found that perception of risk of developing cervical cancer was related to willingness to receive a HPV vaccine. 13 This result is in line with a meta-analysis which reported a positive association between risk perception and vaccination. 14

2 382 European Journal of Public Health Given the news media s emphasis on cervical cancer during September December 2007, the purpose of the present study was to explore the relationship between exposure to television news messages about cervical cancer during that period and women s vulnerability perceptions and fear about cervical cancer. Methods Participants This study used a sample of 500 female respondents who participated in a Health and Media Interview Survey (HMIS) between October and November Interviewers were 308 first-year undergraduate students of a social sciences programme, who received course credit for conducting three standardized face-to-face interviews. All students underwent an interviewer training course, based on an established procedure which has been found to improve data quality. 15 The students were trained in several interviewer skills including methods of random sampling, contacting respondents, applying standardized procedures to administer the questionnaire and the importance of confidentiality. After training, each interviewer received a set of randomly selected interview addresses in the Flemish region of Belgium. At these addresses, the person of the household over the age of 18 who had most recently had a birthday was selected as respondent. Interviewers made up to five contact attempts for each selected respondent. In total, 923 Flemish respondents participated in the study. For the present study, only the female respondents were selected. This study received IRB approval at the Katholieke Universiteit Leuven and all subjects gave informed consent. Prior to each interview, participants were informed about the procedure of the interview and they were assured of anonymity and confidentiality of their responses. Survey answers were kept separately from identifying information of the participants, so that no participant could be linked to his or her responses. At the end of the study, all identifying information was destroyed. Measures The main outcome measures of this study were assessed using a standardized interview-administered questionnaire. The interviewer read each question aloud to the respondent and then filled out the response on a paper questionnaire. For each question, the respondents received vignettes with standardized response options. Demographics Standard questions assessed age and level of education. Age was recorded into a 3-category variable, taking into account the actual risk of getting cervical cancer. Scale values for the new scale were: 1 = ages (low risk group for getting cervical cancer), 2 = ages (high risk group) and 3 = ages >60 (medium risk group). 16 Risk perception of cervical cancer Risk perception was measured by asking the participants: How likely is it that you will get cervical cancer in your lifetime?. Answers were recorded on a 7-point scale from certain not to happen (1) to certain to happen (7). Response options were merged into a 3-point scale with 1 = no chance that it will happen, 2 = moderate chance that it will happen and 3 = large chance that it will happen. A similar one-item measure has been used in previous research on risk perception 17 and has been found to be reliable and valid. 18 Fear of cervical cancer Women rated how much they feared being diagnosed with cervical cancer on a 7-point scale ranging from not at all (1) to very much (7). The cervical cancer fear variable was recorded from a 7-point scale to a 3-point scale such that 1 = not, 2 = moderately and 3 = very. Trait fear We also measured trait fear because higher levels of general anxiety may be related to cancer-specific fear. 19 Women reported to which extent they generally experienced feelings of fear, nervousness, anxiousness and worry on a scale from very little (1) to very much (7) (Cronbach s alpha = 0.78). Item responses were summated to create a composite variable of trait fear. In addition, a medium split was conducted to create a dichotomous variable (0 = low trait anxiety, 1 = high trait anxiety). Personal cervical cancer experience Participants reported whether they had been diagnosed with cervical cancer (0 = no, 1 = yes). Family history and indirect experience of cervical cancer Respondents were asked to indicate whether they knew a family member or friend that had been diagnosed with breast cancer (yes/no). Exposure to cervical cancer messages in television news Television news exposure was assessed with a measure that has previously been used in studies on television exposure and health risk perceptions. 17,20 Women were asked to rate how often they had encountered messages about cervical cancer in television news programmes in the month preceding the administration of the survey (September or October 2007). Response options ranged from never (1), rarely (2), occasionally (3), frequently (4) to very frequently (5). Responses were merged into a 3-point scale such that 1 = never, 2 = occasionally and 3 = frequently. Data analyses analyses were used to examine associations between exposure to cervical cancer messages in television news programmes and level of fear and level of risk perception of cervical cancer. Women who had not been exposed to cervical cancer messages in television news were regarded as the reference group. In subsequent analyses, the models were adjusted for potential confounders. Tables 1 4 show the row percentages, odds ratios (ORs) and 95% confidence intervals (CI). All results reported were two-sided and differences at P-values of 0.05 were accepted as significant. Analyses were performed using SPSS (SPSS 16.0, SPSS Inc., Chicago, IL, USA). Results Respondent characteristics The age of the women in this study ranged from 18 to 85 years (mean age = 43.8). Of the women in our sample, 24.5% were between 18 and 35 years of age, 53.8% were years and 21.7% were 60 years or older. Of the respondents, 10.8% never

3 TV news and cervical cancer 383 finished twelfth grade, 35.2% had some high school education degree and 54% had at least a college education degree. The majority of women had not been diagnosed with cervical cancer (98.6%). Only seven women said that they experienced (or had experienced) cervical cancer (1.4%). Ages of these women ranged from 31 to 62 years. Further, most participants (83.6%) did not know a family member or friend who was (or had been) a cervical cancer patient. Fear of cervical cancer and perceived vulnerability Of the women in our sample, 27.7% reported that they were not of being diagnosed with cervical cancer. One-third of the respondents (33.3%) said they were moderately and 26.9% reported to be very of getting cervical cancer. About 1 out of 10 women (12.2%) felt extremely. Similarly, 23.6% of the participants reported that they felt there was no chance that they would get cervical cancer in their lifetime. Nevertheless, the majority of women (69.1%) assumed that they had a moderate chance. Further, 7.6% estimated that the chance of being diagnosed with cervical cancer was large and none of the participants thought that getting cervical cancer would definitely happen to them. Exposure to television news messages about cervical cancer Of the respondents, 65.4% indicated that they had seen or heard something about cervical cancer in television news programmes in the month preceding the administration of the interview. Of those women, 85.8% said that they had seen or heard messages about cervical cancer occasionally and 14.2% reported that they had been exposed to these messages frequently. Relationship between exposure to cervical cancer messages in television news programmes and fear of cervical cancer Results from the unadjusted model (table 1, panel a) show that exposure to cervical cancer messages on television news was not significantly related to a moderate level of fear. Yet, women who had been occasionally exposed to cervical cancer messages were more than two times more likely to be very (OR = 2.4; 95% CI ), and those who had been frequently exposed were more than three times more likely to be very of being diagnosed with cervical cancer (OR = 3.3; 95% CI ). Women who had frequently seen or heard something about cervical cancer in the news were also more than three times more likely to be extremely of getting cervical cancer (OR = 3.4; 95% CI ). The second analysis in table 1, panel b shows the results for the relationship between exposure to cervical cancer news messages and levels of fear, age factor, level of education, trait fear, direct experience and experience of cervical cancer through family members or friends. The ORs for being very owing to levels of television exposure decreased only slightly. Exposure to cervical cancer news messages, however, was no longer significantly related to extreme fear. Table 2 displays the relationship between the levels of the potential confounders and fear of cervical cancer. Relationship between exposure to cervical cancer messages in television news programmes and perceived risk of cervical cancer Table 3 shows the results of two multinomial regression analyses with levels of risk perception as the main outcome variable. The unadjusted model (table 3, panel a) shows that frequent exposure to cervical cancer messages in the news was related to perceptions of risk about cervical cancer. Women who had been frequently exposed were more than three times more likely to estimate that they had a moderate chance of being diagnosed with cervical cancer (OR = 3.3; 95% CI ) and seven times more likely to report that they had a large chance of getting cervical cancer (OR = 7; 95% CI ). Occasional exposure to messages about cervical cancer in the news was not significantly related to levels of risk perception. Again, the regression model was adjusted for possible confounders (table 3, panel b). The ORs for exposure to cervical cancer messages in television news increased. Table 4 Table 1 Levels of fear of cervical cancer: row percentages and ORs of the multinomial logistic regression analysis for exposure to television news messages about cervical cancer Overall level of fear (row %) Not Moderately Very Extremely Moderately Very Extremely n Row percentages OR 95% CI OR 95% CI OR 95% CI (a) Unadjusted model Exposure to cervical cancer messages in TV news a Never Occasionally ** Frequently * * (b) Adjusted model b Exposure to cervical cancer messages in TV news c Never Occasionally ** Frequently * a: Model Chi-square 17.8, P < 0.05 (df 6) b: ORs were adjusted for age, level of education, personal experience with cervical cancer, indirect experience with cervical cancer and trait fear c: Model Chi-square 74.7, P < (df 27)

4 384 European Journal of Public Health Table 2 Levels of fear of cervical cancer: row percentages and ORs of the multinomial logistic regression analysis for the levels of the confounders Overall level of fear (row %) Confounders Not Moderately Very Extremely Moderately Very Extremely n Row percentages OR 95% CI OR 95% CI OR 95% CI Age group ** ** * Level of education No degree High school degree College degree Direct experience No Yes Indirect experience No Yes Trait fear Low High * * ** Table 3 Levels of perceived risk of cervical cancer: row percentages and ORs of the multinomial logistic regression analysis for exposure to television news messages about cervical cancer Overall level of perceived risk (row %) No risk Moderate risk Large risk Moderate risk Large risk n Row percentages OR 95% CI OR 95% CI (a) Unadjusted model Exposure to cervical cancer messages in TV news a Never % 67.6% 6.5% Occasionally % 69.8% 7.3% Frequently % 76.1% 15.2% 3.3* ** (b) Adjusted model b Exposure to cervical cancer messages in TV news c Never Occasionally Frequently 3.9* ** a: Model Chi-square 9.4, P < 0.05 (df 4) b: ORs were adjusted for age, level of education, personal experience with cervical cancer and indirect experience with cervical cancer c: Model Chi-square 56.8, P < (df 16) shows the odds for perceiving a moderate or large risk of cervical cancer according to levels of confounders that were included in the adjusted model. Discussion While most previous researches have examined awareness or knowledge about cervical cancer, the present study focused on women s vulnerability, perceptions and fear. Furthermore, this study was the first to include exposure to television news messages about cervical cancer as a potential predictor of these determinants of behaviour change. Our results showed that women who were occasionally or regularly exposed to cervical cancer news messages were two to three times more likely to be very of being diagnosed with cervical cancer. Those who were frequently exposed were more than three times more likely to be extremely. Similarly, the odds of perceiving a moderate risk of getting cervical cancer tripled for female viewers who had regularly heard or seen cervical cancer messages. Women who had frequently been exposed to these messages were seven times more likely to perceive a large risk of cervical cancer. From a health promotion perspective, these findings suggest that television news may be an effective tool for public health education. Expensive advertising and social marketing

5 TV news and cervical cancer 385 Table 4 Levels of perceived risk of cervical cancer: row percentages and ORs of the multinomial logistic regression analysis for the levels of the confounders Overall level of perceived risk (row %) Confounders No risk Moderate risk Large risk Moderate risk Large risk n Row percentages OR 95% CI OR 95% CI Age group * * ** * Level of education no degree high school degree college degree ** Direct experience no yes Indirect experience no yes * ** campaigns may have a direct impact on changing health-related outcomes but they may also generate news coverage 21 which in turn seems to influence health behaviour predictors, such as fear and risk perception. Our results, thus, suggest that health promotion practitioners should consider the potential impact of television news messages in health change. More importantly, they should attempt to incorporate news media exposure as a part of health communication campaigns. Health advocacy or public relations are two communication strategies that can be used to influence news media coverage of health issues (e.g. cervical cancer) strategically. Such efforts may increase the effectiveness of television news as a means for health education. 22 Consistent with suggestions made by Niederdeppe et al., 21 our findings also suggest that future research studying outcomes of health campaigns should not merely look into the direct effects of campaign interventions, but should also assess the indirect effects on health outcomes through news coverage. Limitations This study has some limitations that should be taken into account. First, because the data were cross-sectional, findings should be interpreted with caution regarding the causal direction of the relationship. Although we hypothesized that television news exposure would have an impact on risk perception and fear of cervical cancer, it is equally possible that women who had heightened fear and risk perceptions intentionally exposed themselves to television messages about cervical cancer to seek reassurance and to reduce anxiety about the health threat. 23 In addition, other sources, such as commercial advertising by GlaxoSmithKline or campaigns by public health organizations, may have influenced fear and risk perception. Because these campaign messages were broadcasted at the same time the news media increased their coverage on cervical cancer, it is possible that those women who were frequently exposed to television news messages were also frequently exposed to other HPV or cervical cancer television campaigns. Second, the data of this study were collected through self-reports. We asked respondents to report how often they had seen or heard television news messages about cervical cancer. Such a recognition measure might be prone to socially desirable responding or might be influenced by memory errors. However, research has shown that a memory-based measure of exposure was strongly related to past engagement with actual media content. 24 In addition, a study comparing alternative measures of exposure to cancer information in the mass media found that closed-end questions, such as a recall measure, performed well on predictive validity of cancer knowledge, face validity, survey costs and respondent burden. 25 Third, there might have been some interviewer bias or interviewer effects because of the use of student interviewers. To help control for possible bias, students had been trained extensively before the data collection; the survey only contained closed-end standardized questions and all interviewers were kept blind to the research questions and hypotheses of the study. Fourth, although we controlled for several potential confounding variables it is possible that there are other factors which might influence the relationship between television news exposure and fear or risk perception of cervical cancer. Future research should, for example, test for the effects of cervical cancer knowledge or interpersonal communication. Conclusion Overall, the results from this study highlight that television news can be an effective means for health risk communication about cervical cancer. Because fear and risk perception are considered to be important determinants of health behaviour, future studies should investigate the impact of television news on screening and vaccination actions. In addition, future research could benefit from investigating the effects of television news coverage on health determinants and outcomes related to other health problems. Acknowledgements The authors would like to thank the women who participated in this study.

6 386 European Journal of Public Health Funding The Fund for Scientific Research-Flanders (G ). Conflicts of interest: None declared. Key points The introduction of HPV vaccines to the market in 2006 led to an increase in news media attention for cervical cancer. Exposure to television news messages about cervical cancer was related to fear and risk perception of cervical cancer. Because fear and risk perception are considered to be important predictors of preventive health actions, we argue that television news can be an effective means for health education. References 1 Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: cancer incidence, mortality and prevalence worldwide IARC CancerBase No. 5, version 2.0. Lyon: IARC Press, Schiffman M, Castle PE, Jeronimo J, et al. Human papillomavirus and cervical cancer. Lancet 2007;370: Donders GGG, Bellen G, Declerq, A, et al. Change in knowledge of women about cervix cancer, human papilloma virus (HPV) and HPV vaccination due to introduction of HPV vaccines. Eur J Obstet Gynecol Reprod Biol 2009;145: Mediargus. Digital press archive, Brussels: [accessed 6 July 2009]. 5 The European Union Research Group. Eurobarmometer European Union Citizens and Sources of Information about Health. Brussels: Directorate-General Press and Communication, Gerend MA, Magloire ZF. Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults. J Adolesc Health 2008;42: Kelly BJ, Leader AE, Mittermaier DJ, et al. The HPV vaccine and the media: How has the topic been covered and what are the effects on knowledge about the virus and cervical cancer? Patient Educ Couns 2009;77: Kahn JA, Rosentahl SL, Hamann T, Bernstein DI. Attitudes about human papillomavirus vaccine in young women. Int J STD AIDS 2003;14: Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theoryinformed, systematic review. Prev Med 2007;45: Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr 1974;2: Witte K. Putting the fear back into fear appeals: the Extended Parallel Process Model. Commun Monogr 1992;59: Hay JL, Buckley TR, Ostroff JS. The role of cancer worry in cancer screening: a theoretical and empirical review of the literature. Psychooncology 2005;14: Di Giuseppe G, Abbate R, Liguori G, et al. Human papillomavirus and vaccination: knowledge, attitudes, and behavioural intention in adolescents and young women in Italy. Br J Cancer 2008;99: Brewer NT, Chapman GB, Gibbons FX, et al. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol 2007;26: Billiet J, Loosveldt G. Improvement of the quality of responses to factual survey questions by interviewer training. Public Opin Q 1988;52: Gommer AM, Poos MJJC. Nationaal Kompas Volksgezondheid: baarmoederhalskanker prevalentie, incidentie en sterfte naar leeftijd. [accessed 6 July 2009]. 17 Coleman CL. The influence of mass-media and interpersonalcommunication on societal and personal risk judgments. Communic Res 1993;20: Diefenbach MA, Weinstein ND, Oreilly J. Scales for assessing perceptions of health-hazard susceptibility. Health Educ Res 1993;8: Mccaul KD, Branstetter AD, O donnell SM, et al. A descriptive study of breast cancer worry. J Behav Med 1998;21: Snyder LB, Rouse RA. The media can have more than an impersonal impact: the case of AIDS risk perceptions and behavior. Health Commun 1995;7: Niederdeppe J, Farrelly MC, Thomas KY, et al. Newspaper coverage as indirect effects of a health communication intervention: the Florida Tobacco Control Program and youth smoking. Commun Res 2007;34: Randolph W, Viswanath K. Lessons learned from public health mass media campaigns: marketing health in a crowded media world. Annu Rev Public Health 2004;25: Turner MM, Rimal RN, Morrison D, Hyojin K. The role of anxiety in seeking and retaining risk information: testing the risk perception attitude framework in two studies. Hum Commun Res 2006;32: Southwell B, Barmada CH, Hornik RC, Maklan DM. Can we measure encoded exposure? Validation evidence from a national campaign. J Health Commun 2002;7: Romantan A, Hornik R, Price V, et al. A comparative analysis of the performance of alternative measures of exposure. Commun Methods Meas 2008;2:80 99.