Adaptation and Dissemination of a National Cancer Institute HPV Vaccine Evidence-Based Cancer Control Program to the Social Media Messaging Environment

"...learning how promotional and narrative or dialogue-based vaccine messages perform in the competitive social media message environment lends greater external validity...and advances science about which strategies increase reach and engagement under conditions of message competition."

Social media channels offer an opportunity to share accurate, timely, and culturally resonant public health messages, including vaccine messaging. Given that there were 4.70 billion social media users worldwide as of July 2022, these platforms offer a dynamic communication channel for expanding reach to historically underserved populations. However, a gap remains on how to adapt evidence-based vaccine interventions from one-directional dissemination to a dialog-based, push-pull dissemination approach. This paper seeks to fill that gap by describing a 4-month observational social media study examining the processes necessary for adapting the National Cancer Institute (NCI)'s video-based human papillomavirus (HPV) vaccine cancer control programme to the social media environment. It also aims to understand how dissemination might differ across 3 platforms - namely, Instagram, TikTok, and Twitter - to increase reach and engagement.

The push-pull capacity dissemination framework applied to the social media messaging environment includes a "push" intervention component to broadcast vaccine messages to media users and a "pull" component to engage users with intervention content, invite comments, encourage interaction, and share content with peers. Pushing NCI's HPV vaccine content on social media is expected to evoke curiosity and interest in HPV vaccination and to generate more impressions on posted content, while the pull component, which is whether and how various adaptation strategies may engage users, remained an impetus for the study. Also guiding the study is the RE-AIM implementation framework, which proposes that the success of adapting an intervention is best evaluated by 5 dimensions: reach, effectiveness, adoption, implementation, and maintenance.

The NCI's evidence-based cancer control HPV vaccine programme (EBCCP), HPV Vaccine Decision Narratives, is motivated by concern that, in the United States (US), low HPV vaccination rates (aproximately 55%) persist and dropped drastically during the COVID-19 pandemic. The Centers for Disease Control and Prevention (CDC) and all US cancer centres recommend urgent catch-up vaccination. The video-based intervention consists of 5 parent videos and 13 young adult videos. The 1- to 2-minutes videos each present vaccine decision narratives told by youth through informal conversation. Videos were filmed from the perspective of a voyeur witnessing a private dialog between two individuals (mother-daughter, peers, or romantic partners) in informal settings (e.g., in the kitchen). Some videos also reflect conversations between doctors and families in a clinical setting in an exam room.

The EBCCP intervention was adapted and disseminated on social media between February 14 and June 26 2021 using Instagram, TikTok, and Twitter. These platforms are popular among US youth and young adults, for whom HPV vaccination is recommended; in addition, TikTok and Instagram disseminate primarily visual and video-based messages, so they align with the video format of the EBCCP. Centring theory and a question-answer framework guided the adaptation process of segmenting the vaccine decision story videos into shorter segments for social media. Specifically, 12 strategies were implemented over 4 months to build a following and disseminate the intervention; each one is described in detail in the paper, but they include, in brief:

1. Using a strategic handle name (i.e., @realhotgirlshot) adapted from hip hop/rap artists Megan Thee Stallion (@realhotgirlsh*t), who has 26.4 million followers;
2. Segmenting and shortening the EBCCP HPV vaccine videos (click here for one example) into 30-second segments with captions and questions;
3. Strategically using platform features: reels, video length, stories, highlights, geotagging, and polls;
4. Incorporating hashtags and captions to widen reach (e.g., including links, facts, or questions in captions);
5. Inserting a Linktree into each account profile bio to encourage cross-platform engagement;
6. Posting content frequently and regularly - i.e., 3x weekly;
7. Tagging and following influencers (e.g., @CDCgov);
8. Using Instagram's follow-for-follow strategy with those that follow similar accounts;
9. Engaging with similar accounts (e.g., @DenverTeensforVaccines);
10. Using visual aesthetics (e.g., Canva templates) to create a "branded" account with a QR code logo (see image above);
11. Using hot keys (questions) and segmentation of EBCCP videos; and
12. Using timely COVID-19 vaccination as discussion point to engage users. For example, posts focused on the 1-year pandemic anniversary in March 2021 emphasised the importance of getting vaccinated, following CDC guidelines, and tackling misinformation. Debunking COVID-19 myths were shared. The topic of COVID-19 vaccination was used as a conversational segue to talk about HPV vaccination. Pandemic hashtags were used on all posts, including #IGotTheShot, #ThisIsOurShot, #COVID19, and #Pandemic.

Data for the evaluation of the observational study were retrieved from each respective platform's application programming interface and, in the case of Instagram and TikTok, from business accounts that made aggregate-level data accessible on engagement, the number of followers, reach, and impression metrics.

The evaluation showed that all platforms increased following, but Instagram and TikTok outperformed Twitter on impressions, followers, engagement, and reach metrics. Although TikTok increased reach the most (unique accounts that viewed content), Instagram increased followers, engagement, and impressions the most. For Instagram, 6 of 12 strategies contributed to increasing reach, including strategic use of platform features (#3 above), use of hashtags (#4), posting content frequently (#6), tag and follow influencers (#7), hot key segmentation of EBCCP videos (#11), and use of timely COVID-19 vaccination as a discussion point (#12). The paper elaborates on the evidence for these strategies.

This observational social media study identified dissemination strategies that significantly increased the reach of vaccine messages in a real-world competitive social media messaging environment. Findings demonstrate that the inclusion of narrative EBCCP HPV vaccine videos contributed to significantly increasing the average number of accounts reached. Among the lessons learned:

• Engagement presents greater challenges on visual and hedonistic platforms. According to the push-pull communication framework, HPV vaccine messaging was predominantly broadcast, with little organic pull dialogue occurring on these platforms. Organic, user-generated pull communication explained by social affordance theory was not observed. Future research will need to explore which strategies can increase engagement - perhaps network influencers and entertainment memes.
• Although the researchers did not reach mega-influencer Megan Thee Stallion for endorsement of their vaccine account, following local micro-influencers in Orange County, California and public health and tagging HPV vaccine accounts boosted the campaign's following and reach. With an account focused on vaccination, education, and public health, working with influencers who are social activists and care about similar topics may offer one strategy to increase following and engagement with the account.
• Overall, the Linktree cross-platform engagement strategy did not significantly increase following or reach but could still be considered to encourage cross-platform traffic.
• Developing a following can take many months with routine posting and can present challenges, particularly for an account with no name recognition, influencers promoting the account, or viral content. Having adequate time, planning, and resources to manage the account and engage with others is paramount for social media research.
• Posting on specific days and times that followers are on the app is an important strategy. This information is viewable in the analytics for TikTok and Instagram. However, the days and times vary between platforms, and researchers were not always available to post during that time.
• Content that is reposted means it is shared more often and more likely to be seen and, thus, more likely to go viral. The type of content posted, how relatable it is, and how relevant it is to pop culture is something to consider, because contents, such as memes and reels, are known to garner the most exposure on Instagram and Twitter.
• For a research team, having members with a social media background and technical knowledge of marketing strategies for propagating messages and effectively growing accounts is essential. Critical for sustained engagement seems to be the inclusion and posting of trends and topics other than vaccination to maintain interest. For instance, the COVID-19 vaccine posts and hashtags helped broaden the reach and make the campaign's content easier to find for those who did not follow the account but may be interested in keeping up with public health. Framing discussions around topics that are already being discussed both online and offline was a simple way to pull the audience in.

In conclusion: "Social media is a powerful tool that has the potential to revolutionize health interventions if used correctly....Dissemination of HPV vaccine messages will differ depending on the social media platform, but different strategies and a comprehensive strategy are recommended to adapt vaccine interventions, build a following, and increase reach to connect with potential users who may benefit from HPV vaccine messages."