Discordance Between Human Papillomavirus Twitter Images and Disparities in Human Papillomavirus Risk and Disease in the United States: Mixed-Methods Analysis

"Twitter images are an opportune and underutilized resource for studying health communications related to the HPV vaccination."

In the United States (US), racial and ethnic minorities are disproportionately affected by cases of human papillomavirus (HPV)-related cancer, many of which could have been prevented with vaccination. In addition, HPV-related cancer rates have been increasing in men, and vaccine coverage remains disconcertingly low for males of all races and ethnicities. Yet, the initiation and completion rates of HPV vaccination remain low among these populations. Given the importance of social media platforms for health communication, the researchers examined US-based HPV images on Twitter. The objective of the study was to observe whether HPV images on Twitter reflect the actual burden of disease by select demographics and determine to what extent Twitter accounts utilised images that reflect the burden of disease in their health communication messages.

Literature cited here indicates that health promotion messages that are targeted (aimed at the general cultural group) and tailored (aimed at specific individuals within a cultural group) messages can increase perceived cancer risk and cancer information compared with generic messages. Furthermore, previous health communication research has shown the power of imagery. The idea is that including representative images of at-risk groups in health communication images increases awareness, relevance, and impact of a health issue on the group members. Social media can be utilised for health promotion for minorities, particularly in light of data showing that almost one-quarter of internet users, many of whom are from racial and ethnic minorities, use Twitter.

The researchers identified 456 image tweets about HPV that contained faces posted by US users between November 11 2014 and August 8 2016. They then identified images containing at least one human face and utilised the Web-based face recognition tool Face++ to automatically extract the gender, age, and race of each face (as perceived by researchers). They manually annotated the source accounts of these tweets into 3 types as follows: government (38/298, 12.8%), organisations (161/298, 54.0%), and individual (99/298, 33.2%) and topics (news, health, and other) to examine how images varied by message source.

In short, the research revealed that racial minorities and men are less likely to appear in HPV images despite higher rates of HPV incidence. In other words, findings reflected the racial demographics of the US population but not the disease burden (795/1219, 65.22% white faces; 140/1219, 11.48% black faces; 71/1219, 5.82% Asian faces; and 213/1219, 17.47% racially ambiguous faces). Gender disparities were evident in the image faces; 71.70% (874/1219) represented female faces, whereas only 27.89% (340/1219) represented male faces. Among the 11-26 years age group recommended to receive HPV vaccine, HPV images contained more female-only faces (214/616, 34.3%) than males (37/616, 6.0%); the remainder of images included both male and female faces (365/616, 59.3%).

Furthermore, gender and racial disparities were present across different image sources. Faces from government sources were more likely to depict females (n=44) compared with males (n=16). Government HPV images with both genders included predominantly racially ambiguous youth (5/24, 21% female; 3/15, 20% male; and 28/92, 30% both gender), which may reflect an intentional choice to reach a more diverse audience. However, the greater representation of racially ambiguous youth inadvertently fails to address racial and ethnic disparities in HPV health outcomes by underrepresenting those with the highest risk, Of male faces, 80% (12/15) of youth and 100% (1/1) of adults were white. News organisation sources depicted high proportions of white faces (28/38, 97% of female youth and 12/12, 100% of adult males).

According to the researchers, public health agencies would benefit from formative research with minority youth and their parents to improve Web-based health communication strategies to reduce the burden of HPV-associated cancer for all racial and ethnic groups, as well as for men.

They conclude that this study's implications have the potential to inform the development of more culturally relevant messaging, aligning health promotion imagery salient to intended audiences of those disproportionately affected by HPV-related negative health outcomes. Public health agencies can utilise findings to improve health communication approaches on social media whose purpose is to reduce disparities of HPV-associated disease.