Human Papillomavirus Vaccine Messaging on TikTok: Social Media Content Analysis

Abstract

Background.

The human papillomavirus (HPV) vaccine is viewed as a critical tool to protect against six HPV-related cancers. Vaccination is recommended from early adolescence through age 26 years. As young people have become increasingly involved in personal health-related decisions, there is a need to tailor HPV vaccine messaging and reach this priority population on social media and digital outlets. TikTok is a growing social media platform with approximately 70% of its users between the ages of 13 and 24 years.

Purpose.

The aim of this study was to understand HPV vaccine messaging and interactions on TikTok as a needed first step to identifying effective strategies to reach young people with important health messaging.

Methods.

Content analysis was performed on 170 top TikToks focused on the HPV vaccine. TikToks were assessed for content, classification type, and number of interactions.

Results.

Most TikToks were provaccine, while antivaccine TikToks had more user interactions. Cancer and prevention were the main content areas of the analyzed provaccine TikToks, while the side effects were the primary focus of antivaccine messages. Approximately 30% of all top TikToks analyzed were developed by health professionals. TikToks without an explicit vaccine opinion primarily described personal experiences and mentioned side effects most often.

Implications.

TikTok is a growing social media platform that can be used to reach young people and encourage HPV vaccine uptake. Health professionals need to consider the interest that users have in personal experiences and address antivaccine narratives related to side effects.

BACKGROUND

The human papillomavirus (HPV) vaccine protects against six HPV-related cancers and is viewed as a critical tool for cancer prevention (Miller et al., 2014). The Centers for Disease Control and Prevention (CDC) recommends vaccination for both boys and girls between the ages of 9 and 26 years and is often included with routine vaccines given between the ages of 11 and 12 years (CDC, 2020). Guidelines were changed in October 2018 to recommend a shared decision-making process between doctors and patients from age 27 to 45 years when considering vaccination (CDC, 2020).

Uptake of the HPV vaccine in early adolescence is still relatively low in the United States, with 49.8% of adolescent (age 13–17 years) boys and 62.8% of adolescent girls reporting having one or more HPV vaccine shot, well below the 80% national Healthy People 2020 target (Reagan-Steiner et al., 2016). Various barriers to the vaccine, spanning from religion to trust issues, have been identified (Basch & MacLean, 2019). Factors influencing HPV vaccination decisions include pain, fear, risk, parental influence, and the involvement of others (Sisson & Wilkinson, 2019). While the influence of parents on vaccination decisions is often essential, especially as consent is usually needed, young people are increasingly becoming more involved in personal health-related decision making (Sisson & Wilkinson, 2019). This suggests the importance of tailoring HPV vaccination information to both parents and young people (Sisson & Wilkinson, 2019). The internet is an important source of health-related information for young people (Freeman et al., 2018). Furthermore, they use social media at the highest rate of all age-groups, revolutionizing how they share and receive ideas and information, including health-related content (Hausmann et al., 2017).

The 2014 President’s Cancer Panel Report identified the reduced uptake of HPV vaccination in the United States as a critical public health challenge and recommended communication strategies to promote awareness and emphasize safety and benefits (Chido-Amajuoyi et al., 2020). Social media platforms represent a novel way to reach an important audience with recommended HPV vaccination messaging. TikTok is a rapidly expanding social media outlet that features short video clips developed by its users (Basch et al., 2020). While content on various social media platforms has been examined, there are a relatively small number of studies that have assessed public health messaging by TikTok creators (Basch et al., 2020). Over half of all TikTok users (~ 69%) are between the ages of 13 and 24 years of age, making it an ideal outlet to reach a priority population for HPV vaccination (Sehl, 2020).

PURPOSE

The goal of this study was to describe the content of top HPV vaccine TikToks. There were two aims for this study. First, we sought to investigate the content areas of HPV vaccine TikToks to understand associations with user interactions and vaccine opinion. Content areas for this study are defined as the HPV topics that TikToks addressed. Second, we sought to investigate TikTok classification types by assessing associations with vaccine opinion and creator identification as a health professional. Classification types for this study are how creators approached the development of TikToks.

METHOD

A cross-sectional, retrospective, observational review of TikToks was undertaken, aligning with previous studies of public health messaging on social media (El-Awaisi et al., 2020). Qualitative content analysis is a well-known and respected approach to communication-based research on social media (Krippendorff, 2019). This study used summative content analysis to quantify themes, which allowed for analysis to interpret the underlying context (Hsieh & Shannon, 2005). While no studies assessing HPV-related messaging on TikTok have been identified to date, a previous study, which examined the topic on Instagram, used content categories derived from CDC messaging as an approach to content analysis (Basch & MacLean, 2019). A similar technique was adopted for this study. Furthermore, analysis of classification types for health-related posts have been shown to be an effective social media research approach (Rivas et al., 2020). Again, this technique was adopted for this study.

Content categories were established using the CDC HPV Vaccine Information Statement (CDC, 2019). Classification types were based on the findings from Rivas et al. (2020). A coding spreadsheet was created, which included content and classification types among other categories for TikTok characterization. The top TikToks related to HPV vaccination were collected on four separate dates across a 30-day period (September–October 2020). TikToks were identified using six HPV-related hashtags with the most views (#hpvvaccine—81.9K views, #hpvshots—10.7K views, #gardasil—63.3K views, #gardasilshot—12.7K views, #hpv—12.5M views, and #hpvawareness—37.2K). Only TikToks written and recorded in the English language were analyzed. A TikTok had to mention the HPV vaccine in either the video or the written post to be included in the analysis.

Once a TikTok was identified for inclusion in the study, it was categorized by content, classification type, HPV vaccine opinion, gender of creator, and whether it was created by someone identifying as a health professional. In addition, the number of interactions were tallied and tracked. Interactions included the total number of times users chose to click the “like” button, shared the post with their networks, and responded with a comment. Through this process, 170 TikToks were coded by a single researcher for inclusion. Another research team member coded a random selection of 16 TikToks, and a high level of inter-rater reliability was established. Following this coding process, SPSS (v27) was used to conduct Fischer’s exact tests. Statistically significant results were determined if p < .05. Research category 2 exemption was granted for this study by the West Virginia University Institutional Review Board (protocol # 2010147316).

RESULTS

Of the 170 TikToks analyzed, most (71.1%) were created by women versus men (14.7%; see Table 1). While women are the primary users of TikTok (58.8%), this does represent a higher level of content creation compared with men (Clement, 2020). Total interactions per TikTok ranged from 7 to approximately 400K. Identified health professionals created 30.5% of all TikToks analyzed. Most TikToks were classified as either personal experience (47.0%) or educational (30.5%). Content was most frequently related to cancer (31.1%) or prevention (30.0%). The majority (53.5%) of TikToks expressed a provaccination opinion versus an antivaccination opinion (16.4%), or none expressed (30.0%).

TABLE 1.

Characteristics of TikToks Analyzed (n = 170)

Characteristics		n	%
Gender displayed	Women	121	71.1
	Men	25	14.7
	Other	24	14.1
Health professional	Yes	52	30.5
	No/unsure	118	69.4
TikTok classifications	Education	52	30.5
	Personal experience	80	47.0
	Opinion	38	22.3
Number of interactions	500 or fewer	134	78.8
	501–2,500	22	12.9
	2,501+	14	8.2
HPV vaccine opinion	Pro	91	53.5
	Anti	28	16.4
	None given	51	30.0
TikTok content mentionsa	Cancer	53	31.1
	Prevention	51	30.0
	Gender/sex	17	10.0
	Age range	19	11.1
	Doses	9	5.2
	Talk to doctor	6	3.5
	Side effects	56	32.9
	Genital warts	20	11.7

Note. HPV = human papillomavirus.

^aCategories not mutually exclusive.

Cancer (p = .037) and prevention (p = .021) were content categories with the highest number of total interactions (see Table 2). Antivaccine posts had a higher number of total interactions (M = 18040.5, SD = 74587.7), compared with provaccine (M = 1162.4, SD = 2948.4) and no opinion given (M = 317.82, SD = 982.3, p = .024). Provaccine TikToks primarily focused content on cancer (58.2%) and prevention (56.0%), while antivaccine content primarily focused on side effects (75.0%). Of the 51 TikToks that did not give an explicit vaccine opinion, nearly half (45.0%) focused on side effects.

TABLE 2.

Associations of Interactions and Vaccine Opinions With HPV Vaccine TikTok Content Areas

Content areas		Number of interactions (n = 170)				p	Vaccine opinion (n = 119)				p
		1,000 or fewer		1,001+			Provaccine		Antivaccine
		n	%	n	%		n	%	n	%
Cancer	Yes	40	27.8	13	50	.037	53	58.2	0	0.0	<.001
	No	104	75.5	13	50		38	41.8	28	100.0
Prevention	Yes	38	26.4	13	50	.021	51	56.0	0	0.0	<.001
	No	106	73.6	13	50		40	44.0	28	100.0
Gender	Yes	14	9.7	3	11.5	.727	16	17.6	0	0.0	.012
	No	130	90.3	23	88.5		75	82.4	28	100.0
HPV transmission	Yes	11	7.6	2	7.7	1.000	13	14.3	0	0.0	.037
	No	133	92.4	24	92.3		78	85.7	28	100.0
Age range	Yes	15	10.4	4	15.4	.498	19	20.9	0	0.0	.006
	No	129	89.6	22	84.6		72	79.1	28	100.0
Doses	Yes	5	3.5	4	15.4	.032	9	9.9	0	0.0	.113
	No	139	96.5	22	84.6		82	90.1	28	100.0
Talk to doctor	Yes	3	2.1	3	11.5	.047	6	6.6	0	0.0	.334
	No	141	97.9	23	88.5		85	93.4	28	100.0
Side effects	Yes	49	34.0	7	26.9	.651	12	13.2	21	75.0	<.001
	No	95	66.0	19	73.1		79	86.8	7	25.0
Genital warts	Yes	15	10.4	5	19.2	.197	20	22.0	0	0.0	.003
	No	129	89.6	21	80.8		71	78.0	28	100.0

Note. HPV = human papillomavirus. Boldfaced values indicate p < .05.

Provaccine TikToks primarily provided science-based information and were classified as educational (57.1%), while antivaccine TikToks were mainly classified as opinion (64.3%; see Table 3). Of the 51 TikToks that did not present an opinion on the HPV vaccine, all (100.0%) were classified as personal experience. There were statistically significant associations between identification as a health professional and the classification of TikToks. Health professionals were more likely to create educational TikToks (90.0%), while those who did not identify as a health professional focused more on personal experience (63.3%).

TABLE 3.

Associations of Interactions and Health Professional Status With HPV Vaccine TikTok Classification

Classification		Vaccine opinion (n = 119)				p	Health professionals (n = 170)				p
		Provaccine		Antivaccine			Yes		No
		n	%	n	%		n	%	n	%
Personal experience	Yes	20	22.0	10	35.7	.212	4	8.0	76	63.3	<.001
	No	71	78.0	18	64.3		46	92.0	44	36.7
Education	Yes	52	57.1	0	0.0	<.001	45	90.0	7	5.8	<.001
	No	39	42.9	28	100.0		5	10.0	113	94.2
Opinion	Yes	19	20.9	18	64.3	<.001	1	2.0	37	30.8	<.001
	No	72	79.1	10	35.7		49	98.0	83	69.2

Note. HPV = human papillomavirus. Boldfaced values indicate p < .05.

DISCUSSION

These findings suggest that HPV vaccine–related content on TikTok is varied; however, there seem to be patterns of use. Most HPV messaging was related to cancer, prevention, and side effects. Provaccine TikToks adhered to cancer and prevention messaging. In contrast, antivaccine TikToks focused on side effects. For those who did not indicate a pro- or antivaccine stance, there was a focus on side effects. This echoes the findings of a study on HPV messaging on Instagram, which found provaccine posts focused on cancer and prevention while antivaccine posts did not (Basch & MacLean, 2019). This study expands on these findings, suggesting that the content of creators who did not indicate a pro- or antivaccine stance were also found to have focused on messaging outside of cancer and prevention. Like previous studies, most of the top TikToks were provaccine, while antivaccine TikToks had more interactions (Basch & MacLean, 2019; Massey et al., 2020). That said, understanding the full extent of these interactions cannot be ascertained without a thematic analysis of comments. Learning more about how users react to specific TikTok content would be an important next step to providing a complete understanding of interactions.

Health professionals are engaged on this social media outlet, suggesting that they view it as an important platform to reach a younger population with health-related messaging. That said, misinformation is widely available, evident by the large number of interactions with antivaccine posts, like other social media platforms (Basch & MacLean, 2019). This could be confusing for young people who may not have the sophistication needed to appraise health information accurately (Freeman et al., 2018).

It is noteworthy that TikTok users have expressed an interest in personal experiences with the HPV vaccine, including potential side effects. This is particularly important on TikTok as many users are within the ideal age range to receive the HPV vaccine. While health professionals focus primarily on cancer and prevention content, there are fewer provaccine TikToks that take on antivaccine narratives related to side effects. This may be an opportunity for health professionals to reach a younger population and address specific concerns and questions.

Additional research is needed to assess the reactions of young people to HPV vaccine TikToks and social media posts to develop effective content. Furthermore, the lack of men creating HPV vaccine TikToks may be an area that needs to be explored to see if additional messaging strategies are required for this population. In addition, as the age guidelines have expanded to include a shared decision-making process for adults aged between 27 and 45 years, research is needed to see if social media may also be an effective platform to reach this older population with information about the HPV vaccine and if the messaging approach should be different.

The primary limitations of this study are its cross-sectional design and relatively small sample size. Future studies should review TikTok content over a longer period and expand the sample size. In addition, to expanding generalizability, other social media platforms should be analyzed similarly.

IMPLICATIONS

This research approach could be used to study posts on various social media platforms and for other health-related topics. Misinformation about the HPV vaccine is pervasive on social media platforms and is often hidden beyond traditional hashtags such as #HPV or #HPVVaccine (Massey et al., 2020). This indicates the need to characterize interactions in the comment sections of social media posts where misinformation could spread without the use of hashtags. The research approach used for this study could provide the foundation from which to analyze these comments.

Health professionals may feel hesitant to engage on social media, but their interactions are critical to dispelling misinformation (Keller et al., 2014). Initial steps to engaging on social media include creating a professional account that clearly identifies who you are and where you work, sharing only credible information from reliable sources, and identifying the most popular hashtags in the field to increase visibility (Ventola, 2014). This study has shown that provaccine TikToks do garner a high number of interactions, making them an important tool to counter misinformation.

As TikTok rapidly expands its users, composed of primarily young people, HPV vaccine messaging on this platform could provide critical information and support. While provaccine TikToks provide science-based information, it is not clear whether the current messaging resonates with young people. Future research should seek to understand which social media messages encourage behavioral change in young people and encourage them to receive their HPV vaccinations.