Content Analysis of Digital Media Coverage of the Human Papillomavirus Vaccine School-Entry Requirement Policy in Puerto Rico

Content Analysis of Digital Media Coverage of the Human Papillomavirus Vaccine School-Entry Requirement Policy in Puerto Rico | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Content Analysis of Digital Media Coverage of the Human Papillomavirus Vaccine School-Entry Requirement Policy in Puerto Rico Vivian Colón-López, Vilnery Rivera-Figueroa, Glizette O Arroyo-Morales, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-67660/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2021 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11-12 years old. Evidence suggests that the content of media coverage may impact people's perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR. Methods A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach. Results The search resulted in 34 articles in 17 online local and international news outlets that reported on the implementation of the policy. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Conclusions Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR. Health Economics & Outcomes Research Infectious Diseases Health Policy Human papillomavirus HPV Vaccine Implementation School-Entry Policy Requirements Content Analysis Puerto Rico Figures Figure 1 Figure 2 Figure 3 Background High-risk types of human papillomavirus (HPV) cause 91% of cervical cancers and 63-93% of cancers of the vagina, vulva, penis, anus, rectum, and oropharynx (1).During the last decade, multiple studies in Puerto Rico (PR), a United States (US) territory, have documented the burden of HPV infection and HPV-related cancers in this population (2–4). Major findings included an increased risk of cervical cancer in this population compared to mainland US, multiple barriers to cervical cancer screening (5,6), low awareness of HPV and the HPV vaccine (7), increasing trends of anal cancer (8,9) and a higher burden in the incidence and mortality from penile cancer in Puerto Rican men compared with other racial/ethnic groups in the US (10). The magnitude of these needs led to multiple efforts from academia, various local community coalitions, the medical community and other health professionals in PR, aiming to increase community engagement and capacity to reduce the burden of HPV-associated cancers (6,10–18). All these accomplishments led to increases in vaccine uptake over time, and thus higher HPV vaccination rates in PR compared to mainland US. The Healthy People 2020 goal for human papillomavirus (HPV) vaccination for adolescents aged 13 to 18 years is an 80% vaccination rate for the complete HPV series ( Up to Date ) in males and females(19). Estimates from the 2016 National Immunization Survey (NIS), the most recent year available for PR, reported that 75.8% (95% CI: 70.2%–80.6%) of children ages 13-15 years in PR had initiated the first dose of HPV vaccine, and 52.8% (95% CI: 46.4%–59.0%) were up to date with the HPV vaccine series (20). When comparing similar estimates (initiation and up to date) with other US states and jurisdictions, PR had the 6 th highest HPV vaccination rates in that year (21). Only 10 out of 64 states and jurisdictions (including PR) had HPV initiation rates higher than 75%. School-entry requirements are an evidence-based strategy that has been proven effective for increasing coverage rates for other vaccines (22). In August 2018, PR became the 4 th US state or territory to adopt an HPV vaccine school-entry policy, requiring the HPV vaccine for school entrance for children aged 11-12 years, for implementation in August 2018. Three additional states and jurisdictions including Virginia (2008), Washington DC (2009) and Rhode Island (2015) had previously required the HPV vaccine for school entry, and Hawaii subsequently adopted a requirement as of July 2020; although the scope of all the policies enacted so far varies regarding sex, age and number of doses required (23). Virginia and Washington DC passed the laws through a legislative process, while Rhode Island, PR and Hawaii took a regulatory approach using the authority of the Department of Health. Studies evaluating the impact of HPV vaccine school entry requirements in Virginia, DC and Rhode Island on vaccination rates have been inconsistent (24,25), likely due to differences in exemption and enforcement provisions, organizational factors, and parental non-compliance (26,27). Countries with successful vaccination programs have acknowledged the importance of monitoring the media as it might shift perceptions and parental motivations to vaccinate, even in the context of a school requirement (28). The media has been documented as the second most significant source (after health care providers) of information for parents to make vaccination decisions (29). Documentation of how HPV school entry policies and controversy about them are covered in the news media can help understand the context in which the policies are implemented and in which parents make decisions to comply with the policy or not. Methods The aim of this study was to examine the content of online news coverage related to the HPV vaccine school-entry requirement in PR before and after the first year of the implementation. Data Collection A systematic search was conducted using Google ( www.google.com/pr ) to locate digital media reports related to the HPV vaccination policy and its implementation in PR from January 2017 to December 2018. Legitimate news media outlets and blogs (such as: endi.com, elvocero.com, metropr.com, noticel.com) were included in the analysis. The following search terms (in Spanish) were used to identify the online coverage reports: virus de papiloma humano (human papillomavirus) , VPH (HPV) , vacuna OR vacunación contra VPH (vaccine OR HPV vaccine) , implementación (implementation) , Puerto Rico (PR). Only articles that address the HPV school entry policy were included in the analysis. Most of the articles reviewed were from outlets in Puerto Rico and written in Spanish; only one was in English. Other exclusion criteria and analysis performed are presented in Figure 1 . Data Analysis A series of steps were performed in both qualitative and quantitative analyses. First, a classification matrix was developed by the research team to identify if the selected news articles contained information regarding: (a) the policy enactment date and (b) groups impacted by the policy ( e.g . age group, sex), (c) doses required for the HPV vaccine, the d) HPV vaccine prevention messages ( e.g. cancer prevention), and the e) groups cited (e.g. coalitions, Government agencies). Second, using a modified grounded theory approach(30), members of the research team identified emergent themes in the data. A codebook with definitions of each of the codes identified as well as the main themes was developed. We used qualitative data analysis software Atlas.ti (version 8) to facilitate data manipulation and retrieval during analysis. To identify the key themes, coders independently read the transcripts and identify the data by tone (level 1), sub themes (level 2) and codes (level 3) (Figure 2). Research staff discussed conceptual differences regarding coding terminology and established a common set of codes (31). All points of disagreement were resolved through discussion before the remaining articles were analyzed. We compared the frequency of text excerpt by tone and year using the Pearson’s chi-square test. The tests were 2-sided with 0.05 significance levels. The analyses were performed using Stata version 14.1 software (StataCorp LP, College Station, TX). This study was approved by the IRB of the University of Puerto Rico Medical Sciences Campus. Results Search Results Throughout January 2017 to December 2018, 66 news articles were found referring to the search terms used. Only 35 articles satisfied our inclusion criteria by focusing on the school-entry policy, and one of these was not accessible at the time of the analysis (N=34). Figure 1 summarizes the selection of the news articles and analysis derived from articles studied. The search resulted in 17 online local and international media outlets that reported on news related to the HPV school-entry requirement in PR. A total of 18 (53.0%) news articles were gathered in 2017 and 16 (47.0%) from 2018. Descriptive characteristics of article content Descriptive information about the content of the news articles (n=34) derived from the classification matrix is shown in Table 1 . Almost all the news articles reported on the date in which the HPV vaccine school-entry requirement took effect (91.2%). More than half of the news articles included information about cervical cancer (58.8%), while other HPV-related cancers were mentioned less often (11.8% to 23.5%). Most articles highlighted the importance of the vaccine for cancer prevention (79.4%), while around a quarter of the articles discussed HPV as a sexually transmitted infection (STI) (26.4%). Most of the articles did not discuss the number of doses needed to complete the immunization series (38.2% included this information); likewise, information regarding the accessibility of the vaccine was not provided frequently (23.5%). Government agency representatives, followed by coalitions and groups against the implementation, were mostly cited as spokesperson. Negative Media Figure 2 shows the subthemes and the most emerging codes. The most common emerging negative codes were found in the arguments sub-theme, and are the following: 1) infringement of parental and patient autonomy; 2) hesitancy from the political sector (e.g. legislators); 3) hesitancy from groups and coalitions; 4) risk of the vaccine (safety and efficacy); and 5) right to be informed. Infringement of Parental and Patient Autonomy . A total of 17 (5.0%) of the excerpts studied discussed this code, being one of the most emergent topics within negative media . Overall, articles reported negative view s towards the mandate of the vaccine (not HPV vaccination itself). … “vaccines against HPV are a tool for cervical cancer prevention; however, the vaccine should not be mandatory. These stories were mostly presented by coalitions and organizations spokespersons in which they described the need to respect parental autonomy with regards to medical decision-making for their children”. -Spokesperson from local coalitions statement Hesitancy from Groups and Coalitions (5.0%). The negative tone codes highlighted the hesitancy of various groups against the new HPV vaccine school entry policy, which stated different reasons for their hesitancy ( Table 2 ). Some of the groups were not against vaccines, but they expressed hesitation against the mandate. Risk of the vaccine (safety and efficacy) (2.9%). Worry about vaccine safety and discussion of the secondary effects associated with the HPV vaccine were also discussed in the online media outlets. This concern was mostly expressed by coalition groups against the implementation of this vaccination policy. “This project [1303] does not even mention the risks inherent to vaccination. [When you] read [the project] it seems that the vaccines are made from holy water,” - Quote from local coalition spokesperson against HPV school-entry requirement “We are greatly concerned about the lack of orientation on the risks of vaccination. This practice leads to an uninformed or dishonorable consent [without the proper orientation] can put risk health and life at risk” said the organizers. -Quote from local coalition spokesperson against HPV school-entry requirement Information in the news articles noted that the HPV vaccines are a cervical cancer prevention tool; however, they highlighted opinions of some groups that the vaccine should not be mandatory (3.8%). In summary, those coalitions, and groups state that each family, after being properly informed about the vaccine's advantages and risks, should freely decide which of these strategies they want to assume for them and their family health. “[This requirement] needs to be assessed carefully. If it is proven [that the vaccine] is effective and safe, I don't see any problems as long as [this requirement] will not surpass parental choice’’. -Spokesperson of a family organization against HPV school entry requirement Right to be informed (2.7%). Similar to the prior code, most of the people quoted in the articles were not against the HPV vaccine but acknowledged the importance of advocating for understanding the risk and benefits of the vaccine and discussed the right of the parents to be informed. “We are not against vaccines, but what is being [administered] to our children has benefits and risks. It is our right as parents to be informed”. -Local coalition spokesperson against HPV school entry requirement Positive Media Four codes emerged that were positive in tone in the online articles: 1) knowledge and acceptance of the HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; 3) new vaccination law proposal; and 4) support from coalitions, health providers and government representatives for implementation. Cancer Prevention (3.8%) . Many positive tone text excerpts presented prior to and after the implementation of the HPV vaccine school-entry requirement in PR addressed the importance of HPV vaccination for cancer prevention. “…while [representative of a pro-vaccine coalition] states that the increase in oral cancer in Puerto Rico is associated with HPV infection, not only due to tobacco and alcohol use”. -Spokesperson in favor of the HPV school entry requirement The importance of education and protective sexual behaviors. Many coalitions express the need for children to have a sexual health education in schools. “… [coalition group] requested as well that the Puerto Rico Department of Health provide complete information regarding the vaccine, as well as access to preventative sexual health and reproductive health services for youth in schools” -Spokesperson feminist movement New vaccination law proposal (1.8%). Misleading information about the HPV vaccine mandate was disseminated in the media about the bill 1303. Bill 1303 refers to a legislative proposal in PR, presented on November 1 st , 2017, which was intended to create a new law for children and students aiming to strengthen disease prevention through vaccination among these groups(32). This bill also intended to establish an effective process for entering the doses administered to minors and students of the public and private system between the ages of zero into the immunization registry (0) to twenty one (21) years; to empower the DOH of PR to adopt and integrate electronic registration procedures to monitor compliance; and to define the organizations that provide coverage, access and service vaccination, its functions, obligations and accountability. The quotes were unclear if they were in effect talking about the new bill proposed 1303 or the HPV school-entry requirement that would be effective in August 2017. Support from coalitions, health providers and government representatives for implementation (1.5%) . Statements that stressed the importance of HPV vaccination were mostly driven by personal support of the vaccine, whereas coalitions, and other medical and community-based organizations emphasized the importance of this vaccine school-entry requirement for cancer prevention, addressing the burden of HPV and HPV-related cancers in their messages. “Experts urge parents to vaccinate their children by the beginning of the 2017-2018 school year and, if so, complete the corresponding vaccination processes, according to a press release for PR Vaccination Coalition and HPV Advisory Panel.” - Journalist Neutral Media The majority of the media reports published were neutral (58.6%), being the most emergent: 1) description of the HPV-school entry policy; 2) information about HPV-related cancers; 3) general information about the HPV vaccine; 4) information about health care coverage and vaccination centers; 5) controversies surrounding the implementation of HPV vaccine school-entry requirement; and 6) description of the exemptions permitted as part of Law #25. The PR Secretary of Health was the most common spokesperson who disseminated this information. Other news articles provided data from governmental or cancer registry sources, highlighting the burden of cervical cancer and the disparities in cervical cancer incidence in PR in comparison to mainland US. They also stated that these data were fundamental reasons for the decision to implement the HPV vaccine school-entry requirement. Description of the policy (11.8%). Most of the neutral text excerpt disseminated in the media described the policy's announcement when it was going to take place and the required ages. “All students between the ages of 11 and 12 must be vaccinated against the Human Papilloma Virus (HPV) by next year, the government of Puerto Rico ordered on Monday.” - Journalist Information about HPV related cancers (9.4%). Other text excerpts provided data from governmental or registry sources, highlighting the burden of cervical cancer and the disparities in cervical cancer incidence in PR versus mainland US, and stated that these data were fundamental reasons for the decision for to implement the HPV vaccine school-entry requirement. Controversies surrounding the implementation of HPV vaccine school-entry requirement (5.6%). Results from the content analysis highlighted controversies a year prior to the implementation, with disagreement among groups in favor of and against the HPV vaccine school-entry requirement. This text excerpts discuss the polemics that questions the implementation of the HPV vaccine as a requirement and the lack of compliance with the policy. “The vaccine against human papillomavirus (HPV) stirred controversy again since its release to the market 12 years ago, a period in which groups in favor and against [the vaccine] have deliberated on its benefits and risks.” - Journalist “On the one hand, some people applaud the Department of Health initiative so that boys and girls of 11 and 12 years old are inoculated against this disease, after being included in the list of vaccines required for school entry as of August 2018. However, others question the government’s obligation to promote a vaccine that they classify as unsafe and effective due to the experience observed in other countries. Adverse effects have been reported and created organizations of parents against it.” - Journalist Description of the exceptions (4.7%). These text excerpts discussed details regarding the exemption process, explaining that PR only accepts medical and religious exemptions provided via a vaccine exemption affidavit that has to be submitted to the child’s school(33). “The Secretary of Health… said the measure applies to both public and private schools. Parents may disregard the measure for medical or religious reasons if they present an affidavit or a medical certificate.” - Journalist Other neutral codes discussed information regarding coverage of the cost of vaccination through the Vaccine for Children (VFC) Program and accessibility of the vaccine via the government health insurance program (5.9%). Lastly, neutral themes referred to the recommendation of HPV vaccine together with other vaccines (i.e., recommending the HPV vaccine in the same way and at the same visit as Tdap and meningococcal vaccines) (1.5%). Temporal Patterns Across the 17 articles studied, a total of 339 text excerpts were coded as having a positive, negative, and neutral theme, and those who had more than one theme (mixed theme). Figure 3 . shows a distribution of the themes by year. For both years (2017 and 2018), the highest proportion of text excerpts were neutral (61.7% and 55.5%, respectively) towards the HPV vaccine school-entry requirement, followed by negative themes. In 2018, we observed an increase of 0.9% on negative themes compared with 2017. No significant differences across the years were observed by themes (p>0.05). Discussion Previous research has documented how mass media might influence public risk perceptions and decisions about immunization and HPV , but few have examined the context before and prior the implementation of an HPV school entry requirement (28,29,34–37) . The results from our study show that although information regarding the HPV vaccine school-entry requirement was disseminated prior and during the implementation, most of the information during this period was neutral. Changes in themes during this period as well as controversies during the two-year period of the enactment might have led to confusion of the public about the implementation of this mandate. Content analysis of the media's representation of the HPV vaccine worldwide demonstrates that the themes associated with the vaccine are variable, ranging from negative to neutral to positive(38–42). A notable aspect from the media discourse in PR before and after the HPV vaccine school-entry requirement was that media coverage appeared to be more neutral in content than in most countries. Although it is important to acknowledge that the methodology used in different studies varies, a study conducted in Romania showed that (31.4%) of the materials were negative, in the US 14.4% of the media content reported had a similar tone, and a study in the UK which studied newsprint media reported 54.0%. Most of the negative context of the themes analyzed in our study were driven towards the risk of the vaccine, infringement to patient autonomy, right to be informed, and lack of education about HPV and the vaccine. Similar findings were noted in a content analysis of newspaper media from PR; were concerns regarding vaccine safety and parent’s right to choose if they want to vaccinate their children were commonly cited as arguments against the HPV vaccine school-entry requirement(43). Another similar study explored news coverage in states and jurisdictions in which the mandate was implemented, highlighted similar topics(44); and discussed how the concern presented in these articles might negatively impact the HPV vaccine school-entry requirement but also other immunization programs as well. It was noted in our study that the DOH provided most of this neutral content. Scientists or academics were not included as part of this discussion, which might have been a missed opportunity that could have brought robust positive statements in favor of the vaccine and the mandate(45). Movement in opposition mostly stress HPV vaccine safety, patient and parent autonomy rights; those are legitimately issues that can be promoted in educational campaigns and the media. When compared to anti-vax movements worldwide, although similar in scope, the magnitude and impact of these groups on Puerto Rico might differ, which could translate in higher HPV vaccine acceptance rates prior to the requirement and in the increase in other vaccine-preventable diseases as well (46–48). Our analysis showed a shift in the content of the online media from informational (neutral) prior to the implementation to a negative content of information from a coalition against the implementation. This shift was probably driven by the one-year lag period, which was led to promote the new HPV vaccine school-entry requirement. During this period, legislators requested hearings to be informed regarding the safety and efficacy of the vaccine. Since PR’s immunization law authorizes the Secretary of Health to require vaccinations for school-entry, the participation of the Legislature seems to have brought confusion and provoked controversies regarding the implementation of the HPV vaccine school-entry requirement. This also led to the development of a bill, which included philosophical exceptions (49). Although this later bill (1576) was not approved, this period and the mixed information disseminated by the media at the time of the HPV vaccine school-entry requirement might have triggered confusion about the actual implementation. This study adds to the literature on the main themes disseminated prior to the implementation of HPV vaccine school-entry requirements, using PR as an example, and to research on the media coverage of mandates, which may in fact, create a backlash to government-sponsored public health programs (44). However, this study had some limitations. We used a selection of only online news articles focused on HPV vaccine mandates rather than including articles where the HPV vaccine was mentioned, limiting the analysis without news focusing only in HPV and HPV vaccine, which could affect the amount of news with positive and/or neutral content. The small sample of online news articles might affect the qualitative analysis of data. The timeframe established for inclusion criteria to gather the news, which was less than 24 months, and the fact that the media coverage was focused on the school entry policy for HPV vaccination, could also have affected the sample size. Most of the previous studies had an extended timeframe (more than two years) and had a broader HPV-related coverage search (44). Existing search databases were considered for content analysis. However, since access to these databases was restricted and required additional cost and registration (e.g. LexisNexis), and might not contain a broad array of news content in Spanish; we continued with the analysis of digital newspapers with free access. In addition to this, in September 2017, Hurricane Maria harmed the dissemination and publication of information in the news media due to the state of emergency in PR. Nonetheless, the HPV vaccine requirement and legislative activity after the implementation started as planned. Despite these limitations, this effort of understanding the context of the media regarding news related to the HPV vaccine school-entry requirement implementation in important for future public health efforts, particularly given recent changes to the requirement entering the 2019 academic period (expanding to 11-14 years old during the 2019-2020 academic period). However, this decision was also later impacted by environmental disasters in January 2020 (earthquake and continuous seismic activity primarily in the South-west of the island) and the COVID-19 pandemic that might have impacted immunization uptake, hesitation towards the HPV vaccine and might change the narrative and online media discourse on immunization. Conclusions This study explored the content of online media prior and during the first year of implementation of PR’s HPV vaccine school-entry requirement. Vaccine safety and autonomy concerns were common. Detailed information about the vaccine school-entry requirement as well as education on the importance of this policy for the prevention of HPV-related cancers was frequently missing, which could lead to an incomplete picture or lack of understanding of the public health importance of this mandate. Due to the impact that media can have on important immunization strategies, continued monitoring and active participation of coalitions and scientists in favor of these mandates are important. Scientists and providers should insert in the discussion developing content to disseminate the benefits of the vaccine, specifically to neutralize the negative content. Other media sources, such as radio, television, blogs, podcasts, among others, can contribute another aspect or a different level of acceptance to analyze how this content in the analysis can influence the perspective of users related to the HPV vaccine. Future research should continue to monitor news media depictions of the HPV vaccine to assess which themes or controversies remain a pronounced theme of coverage or whether the media ultimately presents the HPV vaccine as an important routine public health service. Abbreviations HPV: Human papilomavirus VPH: Virus del papiloma humano PR: Puerto Rico US: United States NIS: National Immunization Survey STI: Sexually transmitted infections Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: VCL has received compensation from Merck and Co., Inc. for consultancy in June 2020. APO received compensation from Merck and Co., Inc in October 2019 for consultancy. Funding: This work was supported by the National Cancer Institute/National Institute of Health [grant numbers 5R01CA232743] for the Comprehensive Cancer Center of the University of Puerto Rico, Medical Sciences Campus; and the Cancer Prevention Fellowship from the NCI and Harvard T.H. Chan School of Public Health - NIH [grant number 2T32CA057711-26]. Authors' contributions: Vivian Colón-López : Funding acquisition, Supervision, Conceptualization, Methodology, Writing-original draft preparation, Investigation, Validation; Vilnery Rivera-Figueroa : Methodology, Writing-original draft preparation, formal analysis and investigation; Glizette O. Arroyo-Morales : Methodology, Writing-original draft preparation, formal analysis and investigation; Diana T. Medina-Laabes : formal analysis, investigation, Writing- Reviewing and Editing; Roxana Soto-Abreu : formal analysis, investigation, Writing- Reviewing and Editing; Manuel E. Rivera Encarnación : Reviewing: Olga Díaz-Miranda, MS : formal analysis, investigation, Writing- Reviewing and Editing; Ana P. Ortiz, Ph. D : Funding acquisition, formal analysis, investigation, Writing- Reviewing and Editing; Katelyn B. Wells : Funding acquisition, methodology, Writing- Reviewing and Editing; Coralia Vázquez-Otero : Methodology, Writing-original preparation, reviewing and editing and Pamela C. Hull : Funding acquisition, formal analysis, investigation, Writing- Reviewing and Editing Acknowledgment: This publication was supported by the Comprehensive Cancer Center of the UPR (a public corporation of the Government of Puerto Rico created in virtue of Law 230 of August 26, 2004 as amended). The content is entirely the responsibility of the authors and does not necessarily represent the official views of the Comprehensive Cancer Center UPR. References Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, et al. Human Papillomavirus-Associated Cancers - United States, 2008-2012. Morb Mortal Wkly Rep. 2016;65(26):661–6. doi:10.15585/mmwr.mm6526a1 Ortiz AP, Tortolero-Luna G, Romaguera J, Pérez CM, González D, Muñoz C, et al. Seroprevalence of HPV 6, 11, 16 and 18 and correlates of exposure in unvaccinated women aged 16–64 years in Puerto Rico. 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Incidence and mortality rates of selected infection-related cancers in Puerto Rico and in the United States. Infect Agent Cancer. 2010;5(1):1–10. doi:10.1186/1750-9378-5-10 Healthy People. Increase the percentage of female adolescents aged 13 through 15 years who receive 2 or 3 doses of human papillomavirus (HPV) vaccine as recommended [Internet]. Inmunization and Infectious diseases. [cited 2020 Jul 24]. Available from: https://www.healthypeople.gov/node/3527/objectives#4657 Walker TY, Elam-Evans LD, Singleton JA, Yankey D, Markowitz LE, Fredua B, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2016. MMWR Morb Mortal Wkly Rep. 2017 Aug;66(33):874–82. doi:10.15585/mmwr.mm6633a2 National Immunization Survey- Teen. 2016 Adolescent HPV Vaccination Coverage Report [Internet]. Centers for Disease Control and Prevention. 2016 [cited 2018 Sep 24]. Available from: https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/reports/2016.html Community Preventive Services Task Force. What Works Fact Sheet: Increasing Appropriate Vaccination [Internet]. The Community Guide. 2017 [cited 2020 Jun 1]. Available from: https://www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf National Conference of State Legislatures. HPV Vaccine: State Legislation and Statutes. 2017. Available from: https://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx Thompson EL, Livingston MD, Daley EM, Zimet GD. Human papillomavirus vaccine initiation for adolescents following Rhode Island’s school-entry requirement, 2010-2016. Am J Public Health. 2018;108(10):1421–3. doi:10.2105/AJPH.2018.304552 Perkins RB, Lin M, Wallington SF, Hanchate AD. Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009–2013 National Immunization Survey-Teen. Hum Vaccines Immunother [Internet]. 2016;12(6):1615–22. doi:10.1080/21645515.2016.1150394 Omer SB, Richards JL, Ward M, Bednarczyk RA. Vaccination policies and rates of exemption from immunization, 2005-2011. N Engl J Med. 2012 Sep;367(12):1170–1. doi:10.1056/NEJMc1209037 Salmon DA, Omer SB, Moulton LH, Stokley S, Dehart MP, Lett S, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health. 2005 Mar;95(3):436–40. doi:10.2105/AJPH.2004.046201 Suppli CH, Hansen ND, Rasmussen M, Valentiner-Branth P, Krause TG, Mølbak K. Decline in HPV-vaccination uptake in Denmark - The association between HPV-related media coverage and HPV-vaccination. BMC Public Health. 2018;18(1):1–8. doi:10.1186/s12889-018-6268-x Teoh D. The Power of Social Media for HPV Vaccination–Not Fake News! Am Soc Clin Oncol Educ B. 2019;(39):75–8. doi:10.1200/edbk_239363 Krueger R, Casey M. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications; 2009. Kelly BJ, Leader AE, Mittermaier DJ, Hornik RC, Cappella JN. 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 Nov;77(2):308–13. doi:10.1016/j.pec.2009.03.018 Cámara de Representantes. P. de la C. 1303 [Internet]. 2017 [cited 2020 Jun 7]. p. 1–28. Available from: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf Gobierno de Puerto Rico. Ley de las Inmunizaciones Compulsorias a los Niños Pre-escolares y Estudiantes en el Estado Libre Asociado de Puerto Rico [Internet]. 2018 [cited 2020 Jul 24]. p. 1–6. Available from: http://www.bvirtual.ogp.pr.gov/ogp/Bvirtual/leyesreferencia/PDF/Educación (K-12)/25-1983/25-1983.pdf Oubari H, Tuttle R, Rath B, Bravo L. Communicating Vaccine Safety to the Media and General Public. Curr Drug Saf. 2015;10(1):80–6. doi:10.2174/157488631001150407111312 Rousseau C, Moreau N, Dumas MP, Bost I, Lefebvre S, Atlani-Duault L. Public media communications about H1N1, risk perceptions and immunization behaviours: A Quebec–France comparison. Public Underst Sci. 2015;24(2):225–40. doi:10.1177/0963662513495149 Hilton S, Hunt K, Langan M, Bedford H, Petticrew M. Newsprint media representations of the introduction of the HPV vaccination programme for cervical cancer prevention in the UK ( 2005 – 2008 ). Soc Sci Med. 2010;70(6):942–50. doi:10.1016/j.socscimed.2009.11.027 Abdelmutti N, Hoffman-Goetz L. Risk messages about HPV, cervical cancer, and the HPV vaccine Gardasil in North American news magazines. In: Journal of Cancer Education. Springer; 2010. p. 451–6. doi:10.1007/s13187-010-0087-9 Dunn AG, Leask J, Zhou X, Mandl KD, Coiera E. Associations between exposure to and expression of negative opinions about human papillomavirus vaccines on social media: An observational study. J Med Internet Res. 2015;17(6):e144. doi:10.2196/jmir.4343 Margolis MA, Brewer NT, Shah PD, Calo WA, Gilkey MB. Stories about HPV vaccine in social media, traditional media, and conversations. Prev Med (Baltim). 2019;118:251–6. doi:10.1016/j.ypmed.2018.11.005 Briones R, Nan X, Madden K, Waks L. When Vaccines Go Viral: An Analysis of HPV Vaccine Coverage on YouTube. Health Commun. 2012;27(5):478–85. doi:10.1080/10410236.2011.610258 Keelan J, Pavri V, Balakrishnan R, Wilson K. An analysis of the Human Papilloma Virus vaccine debate on MySpace blogs. Vaccine. 2010;28(6):1535–40. doi:10.1016/j.vaccine.2009.11.060 Habel MA, Liddon N, Stryker JE. The HPV vaccine: A content analysis of online news stories. J Women’s Heal. 2009;18(3):401–7. doi:10.1089/jwh.2008.0920 Vazquez-Otero C. Understanding the adoption process of an HPV vaccine school-entry requirement in Puerto Rico. PhD dissertation. Vol. 23. University of South Florida; 2019. Casciotti DM, Smith KC, Andon L, Vernick J, Tsui A, Klassen AC. Print news coverage of school-based human papillomavirus vaccine mandates. J Sch Health. 2014 Feb;84(2):71–81. doi:10.1111/josh.12126 Gollust SE, LoRusso SM, Nagler RH, Fowler EF. Understanding the role of the news media in HPV vaccine uptake in the United States: Synthesis and commentary. Hum Vaccin Immunother. 2016;12(6):1430–4. doi:10.1080/21645515.2015.1109169 Odone A, Ferrari A, Spagnoli F, Visciarelli S, Shefer A, Pasquarella C, et al. Effectiveness of interventions that apply new media to improve vaccine uptake and vaccine coverage. Hum Vaccin Immunother. 2015 Jan 1;11(1):72–82. doi:10.4161/hv.34313 Larson HJ, Wilson R, Hanley S, Parys A, Paterson P. Tracking the global spread of vaccine sentiments: The global response to Japan’s suspension of its HPV vaccine recommendation. Hum Vaccin Immunother. 2014;10(9):2543–50. doi:10.4161/21645515.2014.969618 Okuhara T, Ishikawa H, Okada M, Kato M, Kiuchi T. Amount of narratives used on Japanese Pro- and Anti-HPV vaccination websites: A content analysis. Asian Pacific J Cancer Prev. 2018;19(10):2691–4. doi:10.22034/APJCP.2018.19.10.2691 Cámara de Representantes. P. de la C. 1576 [Internet]. 2018 [cited 2020 Jun 7]. p. 1–7. Available from: http://www.ea-journal.com/images/stories/Art04.02/Pinto-et-al-Vacunacion-obligatoria-y-movimiento-anti-vacuna.pdf Tables Table 1. Content of the Online Media Articles Analyzed Regarding HPV Vaccine School-Entry Requirement: 2017-2018 (n=34 Articles) Topics discussed N Percent (%) HPV-associated cancers Cervical cancer 20 58.8 Oropharyngeal cancer 8 23.5 Penile cancer 7 20.6 Vulvar/vaginal cancer 7 20.6 Anal cancer 4 11.8 Effective date of mandate 31 91.2 Number of doses that are recommended for complete HPV vaccination 13 38.2 Concerns about the efficacy and safety of the vaccine 19 55.9 Highlighted the importance of the vaccine for cancer prevention 27 79.4 Referred to HPV as a STI 9 26.5 Information regarding HPV vaccine accessibility and health coverage 8 23.5 Groups Cited Coalitions Groups Against the Implementation 11 32.4 Government Agency Representatives 29 85.3 Health Professionals 10 29.4 Data and Statistics Institutes 14 41.2 Coalitions Groups In favor of the Implementation 4 11.8 Others 3 8.8 Table 2. Groups against the HPV vaccine school-entry requirement and their reasons. Group Reason against HPV vaccine school-entry requirement Family coalition The vaccine only protects against the most common virus strains and questions its effectiveness. Feminist groups Did not object to the vaccine but question the obligatory nature of the policy since the vaccine has been controversial. Recommend that it be accompanied by vaccine education and sex education. State that each family must decide freely in their health strategies. Local coalitions against HPV school entry requirement Violates the rights of parents in deciding on the care of their children, and they have the right to be informed of the risks of any medical treatment. They understand that the government is obstructing education with this requirement given the high number of vaccines that are imposed annually as part of the school-entry policy and support of the 1576 bill Supplementary Files SupportingInformationBMC.docx Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2021 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Major revision 21 Apr, 2021 Review # 2 received at journal 08 Apr, 2021 Reviewer # 2 agreed at journal 04 Apr, 2021 Review # 1 received at journal 31 Dec, 2020 Reviewer # 1 agreed at journal 16 Dec, 2020 Reviewers invited by journal 29 Sep, 2020 Editor assigned by journal 01 Sep, 2020 Submission checks completed at journal 31 Aug, 2020 Editor invited by journal 31 Aug, 2020 First submitted to journal 27 Aug, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-67660","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2165829,"identity":"ac193961-70a7-406a-8196-f3a9b774400a","order_by":0,"name":"Vivian 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2","display":"","copyAsset":false,"role":"figure","size":74290,"visible":true,"origin":"","legend":"Most emergent codes and subthemes by tones","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-67660/v1/Fig2.jpg"},{"id":2347073,"identity":"730a4199-3c64-4bf5-85ac-56bf5bf6aa04","added_by":"auto","created_at":"2020-09-10 19:13:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30445,"visible":true,"origin":"","legend":"Distribution of theme (n=339) from news articles related to HPV vaccine school-entry requirement in PR.","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-67660/v1/Fig3.jpg"},{"id":13590426,"identity":"ab981b1d-6f17-4fcd-8ca5-d69f31c2d87c","added_by":"auto","created_at":"2021-09-17 05:04:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":428424,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-67660/v1/3c6a44da-9f93-48e8-8889-5b4bb0df1419.pdf"},{"id":2347075,"identity":"d33f11bc-de2f-4703-8080-6a1ab6708ef1","added_by":"auto","created_at":"2020-09-10 19:13:57","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":798854,"visible":true,"origin":"","legend":"","description":"","filename":"SupportingInformationBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-67660/v1/SupportingInformationBMC.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eContent Analysis of Digital Media Coverage of the Human Papillomavirus Vaccine School-Entry Requirement Policy in Puerto Rico\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHigh-risk types of human papillomavirus (HPV) cause 91% of cervical cancers and 63-93% of cancers of the vagina, vulva, penis, anus, rectum, and oropharynx (1).During the last decade, multiple studies in Puerto Rico (PR), a United States (US) territory, have documented the burden of HPV infection and HPV-related cancers in this population (2\u0026ndash;4). Major findings included an increased risk of cervical cancer in this population compared to mainland US, multiple barriers to cervical cancer screening (5,6), low awareness of HPV and the HPV vaccine (7), increasing trends of anal cancer (8,9) and a higher burden in the incidence and mortality from penile cancer in Puerto Rican men compared with other racial/ethnic groups in the US (10). The magnitude of these needs led to multiple efforts from academia, various local community coalitions, the medical community and other health professionals in PR, aiming to increase community engagement and capacity to reduce the burden of HPV-associated cancers (6,10\u0026ndash;18). All these accomplishments led to increases in vaccine uptake over time, and thus higher HPV vaccination rates in PR compared to mainland US.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;Healthy\u0026nbsp;People\u0026nbsp;2020 goal\u0026nbsp;for\u0026nbsp;human papillomavirus\u0026nbsp;(HPV)\u0026nbsp;vaccination\u0026nbsp;for adolescents aged 13 to 18 years is an 80%\u0026nbsp;vaccination\u0026nbsp;rate for the complete HPV series (\u003cem\u003eUp to Date\u003c/em\u003e) \u0026nbsp;in males and females(19). Estimates from the 2016 National Immunization Survey (NIS), the most recent year available for PR, reported that 75.8% (95% CI: 70.2%\u0026ndash;80.6%) of children ages 13-15 years in PR had initiated the first dose of HPV vaccine, and 52.8% (95% CI: 46.4%\u0026ndash;59.0%) were up to date with the HPV vaccine series (20). When comparing similar estimates (initiation and up to date) with other US states and jurisdictions, PR had the 6\u003csup\u003eth\u003c/sup\u003e highest HPV vaccination rates in that year (21). Only 10 out of 64 states and jurisdictions (including PR) had HPV initiation rates higher than 75%.\u003c/p\u003e\n\u003cp\u003eSchool-entry requirements are an evidence-based strategy that has been proven effective for increasing coverage rates for other vaccines (22). In August 2018, PR became the 4\u003csup\u003eth\u003c/sup\u003e US state or territory to adopt an HPV vaccine school-entry policy, requiring the HPV vaccine for school entrance for children aged 11-12 years, for implementation in August 2018. Three additional states and jurisdictions including Virginia (2008), Washington DC (2009) and Rhode Island (2015) had previously required the HPV vaccine for school entry, and Hawaii subsequently adopted a requirement as of July 2020; although the scope of all the policies enacted so far varies regarding sex, age and number of doses required (23). Virginia and Washington DC passed the laws through a legislative process, while Rhode Island, PR and Hawaii took a regulatory approach using the authority of the Department of Health.\u003c/p\u003e\n\u003cp\u003eStudies evaluating the impact of HPV vaccine school entry requirements in Virginia, DC and Rhode Island on vaccination rates have been inconsistent (24,25), likely due to differences in exemption and enforcement provisions, organizational factors, and parental non-compliance (26,27). Countries with successful vaccination programs have acknowledged the importance of monitoring the media as it might shift perceptions and parental motivations to vaccinate, even in the context of a school requirement (28). The media has been documented as the second most significant source (after health care providers) of information for parents to make vaccination decisions (29). Documentation of how HPV school entry policies and controversy about them are covered in the news media can help understand the context in which the policies are implemented and in which parents make decisions to comply with the policy or not.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe aim of this study was to examine the content of online news coverage related to the HPV vaccine school-entry requirement in PR before and after the first year of the implementation.\u003c/p\u003e\n\u003cp\u003eData Collection\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A systematic search was conducted using Google (\u003ca href=\"http://www.google.com/pr\"\u003ewww.google.com/pr\u003c/a\u003e) to locate digital media reports related to the HPV vaccination policy and its implementation in PR from January 2017 to December 2018. Legitimate news media outlets and blogs (such as: endi.com, elvocero.com, metropr.com, noticel.com) were included in the analysis. The following search terms (in Spanish) were used to identify the online coverage reports: \u003cem\u003evirus de papiloma humano \u003c/em\u003e(human papillomavirus)\u003cem\u003e, VPH \u003c/em\u003e(HPV)\u003cem\u003e, vacuna OR vacunaci\u0026oacute;n contra VPH \u003c/em\u003e(vaccine OR HPV vaccine)\u003cem\u003e, implementaci\u0026oacute;n \u003c/em\u003e(implementation)\u003cem\u003e, \u003c/em\u003ePuerto Rico (PR). Only articles that address the HPV school entry policy were included in the analysis. Most of the articles reviewed were from outlets in Puerto Rico and written in Spanish; only one was in English. Other exclusion criteria and analysis performed are presented in \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eData Analysis\u003c/p\u003e\n\u003cp\u003eA series of steps were performed in both qualitative and quantitative analyses. First, a classification matrix was developed by the research team to identify if the selected news articles contained information regarding: (a) the policy enactment date and (b) groups impacted by the policy (\u003cem\u003ee.g\u003c/em\u003e. age group, sex), (c) doses required for the HPV vaccine, the d) HPV vaccine prevention messages (\u003cem\u003ee.g.\u003c/em\u003e cancer prevention), and the e) groups cited (e.g. coalitions, Government agencies). Second, using a modified grounded theory approach(30), members of the research team identified emergent themes in the data. A codebook with definitions of each of the codes identified as well as the main themes was developed. We used qualitative data analysis software \u003cem\u003eAtlas.ti\u003c/em\u003e (version 8) to facilitate data manipulation and retrieval during analysis. To identify the key themes, coders independently read the transcripts and identify the data \u003cem\u003eby tone (level 1), \u003c/em\u003e\u003cem\u003esub themes (level 2) and codes (level 3) \u003c/em\u003e\u003cstrong\u003e(Figure 2).\u003c/strong\u003e\u0026nbsp; Research staff discussed conceptual differences regarding coding terminology and established a common set of codes (31). All points of disagreement were resolved through discussion before the remaining articles were analyzed. We compared the frequency of text excerpt by tone and year using the Pearson\u0026rsquo;s chi-square test.\u0026nbsp; The tests were 2-sided with 0.05 significance levels. The analyses were performed using Stata version 14.1 software (StataCorp LP, College Station, TX). This study was approved by the IRB of the University of Puerto Rico Medical Sciences Campus.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eSearch Results\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThroughout January 2017 to December 2018, 66 news articles were found referring to the search terms used. Only 35 articles satisfied our inclusion criteria by focusing on the school-entry policy, and one of these was not accessible at the time of the analysis (N=34). \u003cstrong\u003eFigure 1\u003c/strong\u003e summarizes the selection of the news articles and analysis derived from articles studied. The search resulted in 17 online local and international media outlets that reported on news related to the HPV school-entry requirement in PR. A total of 18 (53.0%) news articles were gathered in 2017 and 16 (47.0%) from 2018.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDescriptive characteristics of article content\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive information about the content of the news articles (n=34) derived from the classification matrix is shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Almost all the news articles reported on the date in which the HPV vaccine school-entry requirement took effect (91.2%). More than half of the news articles included information about cervical cancer (58.8%), while other HPV-related cancers were mentioned less often (11.8% to 23.5%). Most articles highlighted the importance of the vaccine for cancer prevention (79.4%), while around a quarter of the articles discussed HPV as a sexually transmitted infection (STI) (26.4%). Most of the articles did not discuss the number of doses needed to complete the immunization series (38.2% included this information); likewise, information regarding the accessibility of the vaccine was not provided frequently (23.5%). Government agency representatives, followed by coalitions and groups against the implementation, were mostly cited as spokesperson.\u003c/p\u003e\n\u003cp\u003eNegative Media\u003c/p\u003e\n\u003cp\u003eFigure 2 shows the subthemes and the most emerging codes. The most common emerging negative codes were found in the arguments sub-theme, and are the following: 1) infringement of parental and patient autonomy; 2) hesitancy from the political sector (e.g. legislators); 3) hesitancy from groups and coalitions; 4) risk of the vaccine (safety and efficacy); and 5) right to be informed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInfringement of Parental and Patient Autonomy\u003c/em\u003e. A total of 17 (5.0%) of the excerpts studied discussed this code, being one of the most emergent topics within negative media\u003cem\u003e. \u003c/em\u003eOverall, articles reported negative view\u003cem\u003es\u003c/em\u003e towards the mandate of the vaccine (not HPV vaccination itself).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026hellip; \u0026ldquo;vaccines against HPV are a tool for cervical cancer prevention; however, the vaccine should not be mandatory. \u003c/em\u003e\u003cem\u003eThese stories were mostly presented by coalitions and organizations spokespersons in which they described the need to respect parental autonomy with regards to medical decision-making for their children\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;-Spokesperson from \u003cem\u003elocal coalitions statement \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHesitancy from Groups and Coalitions (5.0%). \u003c/em\u003eThe negative tone codes highlighted the hesitancy of various groups against the new HPV vaccine school entry policy, which stated different reasons for their hesitancy (\u003cstrong\u003eTable 2\u003c/strong\u003e). Some of the groups were not against vaccines, but they expressed hesitation against the mandate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRisk of the vaccine (safety and efficacy) (2.9%). \u003c/em\u003eWorry about vaccine safety and discussion of the secondary effects associated with the HPV vaccine were also discussed in the online media outlets. This concern was mostly expressed by coalition groups against the implementation of this vaccination policy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This project [1303] does not even mention the risks inherent to vaccination. [When you] read [the project] it seems that the vaccines are made from holy water,\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e-\u003cem\u003eQuote from local coalition spokesperson against HPV school-entry requirement \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are greatly concerned about the lack of orientation on the risks of vaccination. This practice leads to an uninformed or dishonorable consent [without the proper orientation] can put risk health and life at risk\u0026rdquo; said the organizers.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e-Quote from local coalition spokesperson against HPV school-entry requirement \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInformation in the news articles noted that the HPV vaccines are a cervical cancer prevention tool; however, they highlighted opinions of some groups that the vaccine should not be mandatory (3.8%).\u0026nbsp; In summary, those coalitions, and groups state that each family, after being properly informed about the vaccine's advantages and risks, should freely decide which of these strategies they want to assume for them and their family health.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[This requirement] needs to be assessed carefully. If it is proven [that the vaccine] is effective and safe, I don't see any problems as long as [this requirement] will not surpass parental choice\u0026rsquo;\u0026rsquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e-Spokesperson of a family organization against HPV school entry requirement \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRight to be informed (2.7%). \u003c/em\u003eSimilar to the prior code, most of the people quoted in the articles were not against the HPV vaccine but acknowledged the importance of advocating for understanding the risk and benefits of the vaccine and discussed the right of the parents to be informed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We are not against vaccines, but what is being [administered] to our children has benefits and risks. It is our right as parents to be informed\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e-Local coalition spokesperson against HPV school entry requirement \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePositive Media\u003c/p\u003e\n\u003cp\u003eFour codes emerged that were positive in tone in the online articles: 1) knowledge and acceptance of the HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; 3) new vaccination law proposal; and 4) support from coalitions, health providers and government representatives for implementation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCancer Prevention (3.8%)\u003c/em\u003e. Many positive tone text excerpts presented prior to and after the implementation of the HPV vaccine school-entry requirement in PR addressed the importance of HPV vaccination for cancer prevention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;while [representative of a pro-vaccine coalition] states that the increase in oral cancer in Puerto Rico is associated with HPV infection, not only due to tobacco and alcohol use\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e-Spokesperson in favor of the HPV school entry requirement\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe importance of education and protective sexual behaviors.\u003c/em\u003e Many coalitions express the need for children to have a sexual health education in schools.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; [coalition group] requested as well that the Puerto Rico Department of Health provide complete information regarding the vaccine, as well as access to preventative sexual health and reproductive health services for youth in schools\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e-Spokesperson feminist movement\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNew vaccination law proposal (1.8%). \u003c/em\u003eMisleading information about the HPV vaccine mandate was disseminated in the media about the bill 1303. Bill 1303 refers to a legislative proposal in PR, presented on November 1\u003csup\u003est\u003c/sup\u003e, 2017, which was intended to create a new law for children and students aiming to strengthen disease prevention through vaccination among these groups(32). This bill also intended to establish an effective process for entering the doses administered to minors and students of the public and private system between the ages of zero into the immunization registry (0) to twenty one (21) years; to empower the DOH of PR to adopt and integrate electronic registration procedures to monitor compliance; and to define the organizations that provide coverage, access and service vaccination, its functions, obligations and accountability. The quotes were unclear if they were in effect talking about the new bill proposed 1303 or the HPV school-entry requirement that would be effective in August 2017.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSupport from coalitions, health providers and government representatives for implementation (1.5%)\u003c/em\u003e. Statements that stressed the importance of HPV vaccination were mostly driven by personal support of the vaccine, whereas coalitions, and other medical and community-based organizations emphasized the importance of this vaccine school-entry requirement for cancer prevention, addressing the burden of HPV and HPV-related cancers in their messages.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Experts urge parents to vaccinate their children by the beginning of the 2017-2018 school year and, if so, complete the corresponding vaccination processes, according to a press release for PR Vaccination Coalition and HPV Advisory Panel.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e- Journalist\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNeutral Media\u003c/p\u003e\n\u003cp\u003eThe majority of the media reports published were neutral (58.6%), being the most emergent: 1) description of the HPV-school entry policy; 2) information about HPV-related cancers; 3) general information about the HPV vaccine; 4) information about health care coverage and vaccination centers; 5) controversies surrounding the implementation of HPV vaccine school-entry requirement; and 6) description of the exemptions permitted as part of Law #25. The PR Secretary of Health was the most common spokesperson who disseminated this information. Other news articles provided data from governmental or cancer registry sources, highlighting the burden of cervical cancer and the disparities in cervical cancer incidence in PR in comparison to mainland US. They also stated that these data were fundamental reasons for the decision to implement the HPV vaccine school-entry requirement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDescription of the policy (11.8%). \u003c/em\u003eMost of the neutral text excerpt disseminated in the media described the policy's announcement when it was going to take place and the required ages.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;All students between the ages of 11 and 12 must be vaccinated against the Human Papilloma Virus (HPV) by next year, the government of Puerto Rico ordered on Monday.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e- Journalist\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformation about HPV related cancers (9.4%). \u003c/em\u003eOther text excerpts provided data from governmental or registry sources, highlighting the burden of cervical cancer and the disparities in cervical cancer incidence in PR versus mainland US, and stated that these data were fundamental reasons for the decision for to implement the HPV vaccine school-entry requirement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eControversies surrounding the implementation of HPV vaccine school-entry requirement (5.6%).\u003c/em\u003e Results from the content analysis highlighted controversies a year prior to the implementation, with disagreement among groups in favor of and against the HPV vaccine school-entry requirement. This text excerpts discuss the polemics that questions the implementation of the HPV vaccine as a requirement and the lack of compliance with the policy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The vaccine against human papillomavirus (HPV) stirred controversy again since its release to the market 12 years ago, a period in which groups in favor and against [the vaccine] have deliberated on its benefits and risks.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- Journalist\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026ldquo;On the one hand, some people applaud the Department of Health initiative so that boys and girls of 11 and 12 years old are inoculated against this disease, after being included in the list of vaccines required for school entry as of August 2018. However, others question the government\u0026rsquo;s obligation to promote a vaccine that they classify as unsafe and effective due to the experience observed in other countries. Adverse effects have been reported and created organizations of parents against it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e- Journalist\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDescription of the exceptions (4.7%). \u003c/em\u003eThese text excerpts discussed details regarding the exemption process, explaining that PR only accepts medical and religious exemptions provided via a vaccine exemption affidavit that has to be submitted to the child\u0026rsquo;s school(33).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The Secretary of Health\u0026hellip; said the measure applies to both public and private schools. Parents may disregard the measure for medical or religious reasons if they present an affidavit or a medical certificate.\u0026rdquo; \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e- Journalist\u003c/p\u003e\n\u003cp\u003eOther neutral codes discussed information regarding coverage of the cost of vaccination through the Vaccine for Children (VFC) Program and accessibility of the vaccine via the government health insurance program (5.9%). Lastly, neutral themes referred to the recommendation of HPV vaccine together with other vaccines (i.e., recommending\u0026nbsp;the\u0026nbsp;HPV vaccine\u0026nbsp;in the same way and at the same visit as Tdap and meningococcal\u0026nbsp;vaccines) (1.5%).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTemporal Patterns \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross the 17 articles studied, a total of 339 text excerpts were coded as having a positive, negative, and neutral theme, and those who had more than one theme (mixed theme). \u003cstrong\u003eFigure 3\u003c/strong\u003e. shows a distribution of the themes by year. For both years (2017 and 2018), the highest proportion of text excerpts were neutral (61.7% and 55.5%, respectively) towards the HPV vaccine school-entry requirement, followed by negative themes. In 2018, we observed an increase of 0.9% on negative themes compared with 2017. No significant differences across the years were observed by themes (p\u0026gt;0.05).\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003ePrevious research has documented how mass media might influence public risk perceptions and decisions about immunization and HPV , but few have examined the context before and prior the implementation of an HPV school entry requirement (28,29,34\u0026ndash;37)\u003cem\u003e.\u003c/em\u003e The results from our study show that although information regarding the HPV vaccine school-entry requirement was disseminated prior and during the implementation, most of the information during this period was neutral. Changes in themes during this period as well as controversies during the two-year period of the enactment might have led to confusion of the public about the implementation of this mandate.\u003c/p\u003e\n\u003cp\u003eContent analysis of the media's representation of the HPV vaccine worldwide demonstrates that the themes associated with the vaccine are variable, ranging from negative to neutral to positive(38\u0026ndash;42). A notable aspect from the media discourse in PR before and after the HPV vaccine school-entry requirement was that media coverage appeared to be more neutral in content than in most countries. Although it is important to acknowledge that the methodology used in different studies varies, a study conducted in Romania showed that (31.4%) of the materials were negative, in the US 14.4% of the media content reported had a similar tone, and a study in the UK which studied newsprint media reported 54.0%. Most of the negative context of the themes analyzed in our study were driven towards the risk of the vaccine, infringement to patient autonomy, right to be informed, and lack of education about HPV and the vaccine. Similar findings were noted in a content analysis of newspaper media from PR; were concerns regarding vaccine safety and parent\u0026rsquo;s right to choose if they want to vaccinate their children were commonly cited as arguments against the HPV vaccine school-entry requirement(43). Another similar study explored news coverage in states and jurisdictions in which the mandate was implemented, highlighted similar topics(44); and discussed how the concern presented in these articles might negatively impact the HPV vaccine school-entry requirement but also other immunization programs as well.\u003c/p\u003e\n\u003cp\u003eIt was noted in our study that the DOH provided most of this neutral content. Scientists or academics were not included as part of this discussion, which might have been a missed opportunity that could have brought robust positive statements in favor of the vaccine and the mandate(45). Movement in opposition mostly stress HPV vaccine safety, patient and parent autonomy rights; those are legitimately issues that can be promoted in educational campaigns and the media. When compared to anti-vax movements worldwide, although similar in scope, the magnitude and impact of these groups on Puerto Rico might differ, which could translate in higher HPV vaccine acceptance rates prior to the requirement and in the increase in other vaccine-preventable diseases as well (46\u0026ndash;48).\u003c/p\u003e\n\u003cp\u003eOur analysis showed a shift in the content of the online media from informational (neutral) prior to the implementation to a negative content of information from a coalition against the implementation. This shift was probably driven by the one-year lag period, which was led to promote the new HPV vaccine school-entry requirement. During this period, legislators requested hearings to be informed regarding the safety and efficacy of the vaccine. Since PR\u0026rsquo;s immunization law authorizes the Secretary of Health to require vaccinations for school-entry, the participation of the Legislature seems to have brought confusion and provoked controversies regarding the implementation of the HPV vaccine school-entry requirement. This also led to the development of a bill, which included philosophical exceptions (49). Although this later bill (1576) was not approved, this period and the mixed information disseminated by the media at the time of the HPV vaccine school-entry requirement might have triggered confusion about the actual implementation.\u003c/p\u003e\n\u003cp\u003eThis study adds to the literature on the main themes disseminated prior to the implementation of HPV vaccine school-entry requirements, using PR as an example,\u0026nbsp; and to research on the media coverage of mandates, which may in fact, create a backlash to government-sponsored public health programs (44). However, this study had some limitations. We used a selection of only online news articles focused on HPV vaccine mandates rather than including articles where the HPV vaccine was mentioned, limiting the analysis without news focusing only in HPV and HPV vaccine, which could affect the amount of news with positive and/or neutral content. The small sample of online news articles might affect the qualitative analysis of data. The timeframe established for inclusion criteria to gather the news, which was less than 24 months, and the fact that the media coverage was focused on the school entry policy for HPV vaccination, could also have affected the sample size. Most of the previous studies had an extended timeframe (more than two years) and had a broader HPV-related coverage search (44).\u0026nbsp; Existing search databases were considered for content analysis. However, since access to these databases was restricted and required additional cost and registration (e.g. LexisNexis), and might not contain a broad array of news content in Spanish; we continued with the analysis of digital newspapers with free access. In addition to this, in September 2017, Hurricane Maria harmed the dissemination and publication of information in the news media due to the state of emergency in PR. Nonetheless, the HPV vaccine requirement and legislative activity after the implementation started as planned.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, this effort of understanding the context of the media regarding news related to the HPV vaccine school-entry requirement implementation in important for future public health efforts, particularly given recent changes to the requirement entering the 2019 academic period (expanding to 11-14 years old during the 2019-2020 academic period). However, this decision was also later impacted by environmental disasters in January 2020 (earthquake and continuous seismic activity primarily in the South-west of the island) and the COVID-19 pandemic that might have impacted immunization uptake, hesitation towards the HPV vaccine and might change the narrative and online media discourse on immunization.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study explored the content of online media prior and during the first year of implementation of PR\u0026rsquo;s HPV vaccine school-entry requirement. Vaccine safety and autonomy concerns were common. Detailed information about the vaccine school-entry requirement as well as education on the importance of this policy for the prevention of HPV-related cancers was frequently missing, which could lead to an incomplete picture or lack of understanding of the public health importance of this mandate. Due to the impact that media can have on important immunization strategies, continued monitoring and active participation of coalitions and scientists in favor of these mandates are important. Scientists and providers should insert in the discussion developing content to disseminate the benefits of the vaccine, specifically to neutralize the negative content. Other media sources, such as radio, television, blogs, podcasts, among others, can contribute another aspect or a different level of acceptance to analyze how this content in the analysis can influence the perspective of users related to the HPV vaccine. Future research should continue to monitor news media depictions of the HPV vaccine to assess which themes or controversies remain a pronounced theme of coverage or whether the media ultimately presents the HPV vaccine as an important routine public health service.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHPV: Human papilomavirus\u003c/p\u003e\n\u003cp\u003eVPH: Virus del papiloma humano\u003c/p\u003e\n\u003cp\u003ePR: Puerto Rico\u003c/p\u003e\n\u003cp\u003eUS: United States\u003c/p\u003e\n\u003cp\u003eNIS: National Immunization Survey\u003c/p\u003e\n\u003cp\u003eSTI: Sexually transmitted infections\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate: \u003c/em\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials: \u003c/em\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests: \u003c/em\u003eVCL has received compensation from Merck and Co., Inc. for consultancy in June 2020. APO received compensation from Merck and Co., Inc in October 2019 for consultancy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding: \u003c/em\u003eThis work was supported by the National Cancer Institute/National Institute of Health [grant numbers 5R01CA232743] for the Comprehensive Cancer Center of the University of Puerto Rico, Medical Sciences Campus; and the Cancer Prevention Fellowship from the NCI and Harvard T.H. Chan School of Public Health - NIH [grant number 2T32CA057711-26].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions: \u003c/em\u003e\u003cu\u003eVivian Col\u0026oacute;n-L\u0026oacute;pez\u003c/u\u003e: Funding acquisition, Supervision, Conceptualization, Methodology, Writing-original draft preparation, Investigation, Validation; \u003cu\u003eVilnery Rivera-Figueroa\u003c/u\u003e: Methodology, Writing-original draft preparation, formal analysis and investigation; \u003cu\u003eGlizette O. Arroyo-Morales\u003c/u\u003e: Methodology, Writing-original draft preparation, formal analysis and investigation; \u003cu\u003eDiana T. Medina-Laabes\u003c/u\u003e: formal analysis, investigation, Writing- Reviewing and Editing; \u003cu\u003eRoxana Soto-Abreu\u003c/u\u003e: formal analysis, investigation, Writing- Reviewing and Editing; \u003cu\u003eManuel E. Rivera Encarnaci\u0026oacute;n\u003c/u\u003e: Reviewing: \u003cu\u003eOlga D\u0026iacute;az-Miranda, MS\u003c/u\u003e: formal analysis, investigation, Writing- Reviewing and Editing; \u003cu\u003eAna P. Ortiz, Ph. D\u003c/u\u003e: Funding acquisition, formal analysis, investigation, Writing- Reviewing and Editing; \u003cu\u003eKatelyn B. Wells\u003c/u\u003e: Funding acquisition, methodology, Writing- Reviewing and Editing; \u003cu\u003eCoralia\u003c/u\u003e\u003cu\u003eV\u0026aacute;zquez-Otero\u003c/u\u003e: Methodology, Writing-original preparation, reviewing and editing and \u003cu\u003ePamela C. Hull\u003c/u\u003e: Funding acquisition, formal analysis, investigation, Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgment: \u003c/em\u003eThis publication was supported by the Comprehensive Cancer Center of the UPR (a public corporation of the Government of Puerto Rico created in virtue of Law 230 of August 26, 2004 as amended).\u0026nbsp; The content is entirely the responsibility of the authors and does not necessarily represent the official views of the Comprehensive Cancer Center UPR.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eViens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, et al. Human Papillomavirus-Associated Cancers - United States, 2008-2012. Morb Mortal Wkly Rep. 2016;65(26):661\u0026ndash;6. doi:10.15585/mmwr.mm6526a1\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Tortolero-Luna G, Romaguera J, P\u0026eacute;rez CM, Gonz\u0026aacute;lez D, Mu\u0026ntilde;oz C, et al. Seroprevalence of HPV 6, 11, 16 and 18 and correlates of exposure in unvaccinated women aged 16\u0026ndash;64 years in Puerto Rico. Papillomavirus Res. 2018 Jun 1;5:109\u0026ndash;13. doi:10.1016/j.pvr.2018.03.006\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Tamayo V, Scorsone A, Soto-Salgado M, Febo I, Piovanetti P, et al. Prevalence and correlates of cervical HPV infection in a clinic-based sample of HIV-positive Hispanic women. Papillomavirus Res [Internet]. 2017;4(February):39\u0026ndash;44. doi:10.1016/j.pvr.2017.06.006\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Romaguera J, P\u0026eacute;rez CM, Gonz\u0026aacute;lez D, Mu\u0026ntilde;oz C, Gonz\u0026aacute;lez L, et al. Prevalence, genotyping, and correlates of anogenital HPV infection in a population-based sample of women in Puerto Rico. Papillomavirus Res. 2016 ;2:89\u0026ndash;96. doi:10.1016/j.pvr.2016.04.002\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez CM, Gonz\u0026aacute;lez-Barrios D, Ramos-Cartagena JM, Ortiz AP. Association of Body Mass Index with Adherence to Cervical Cancer Screening Recommendations in Hispanic Women. J Low Genit Tract Dis. 2020 Jan 1;24(1):14\u0026ndash;20. doi:10.1097/LGT.0000000000000504\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Hebl S, Serrano R, Fernandez ME, Suarez E, Tortolero-Luna G. Factors associated with cervical cancer screening in Puerto Rico. Prev Chronic Dis. 2010;7(3).\u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez ME, Le YCL, Fern\u0026aacute;ndez-Espada N, Calo WA, Savas LS, V\u0026eacute;lez C, et al. Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: A qualitative study. Prev Chronic Dis. 2014;11(12). doi:10.5888/pcd11.140171\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Ortiz-Ortiz KJ, Traverso-Ortiz M, R\u0026iacute;os MY, Col\u0026oacute;n-L\u0026oacute;pez V, Palefsky JM. Anal cancer trends in Puerto Rico from 1985 to 2005: The potential impact of the AIDS epidemic. AIDS Patient Care STDS. 2014 Apr 1;28(4):165\u0026ndash;7. doi:10.1089/apc.2013.0365\u003c/li\u003e\n\u003cli\u003eAcevedo-Font\u0026aacute;nez AI, Su\u0026aacute;rez E, Torres Cintr\u0026oacute;n CR, Ortiz AP. Risk of Anal Cancer in Women With a Human Papillomavirus\u0026ndash;Related Gynecological Neoplasm. J Low Genit Tract Dis [Internet]. 2018 Jul 1 [cited 2020 Jun 24];22(3):225\u0026ndash;30. Available from: http://journals.lww.com/00128360-201807000-00010. doi:10.1097/LGT.0000000000000395\u003c/li\u003e\n\u003cli\u003eCol\u0026oacute;n-L\u0026oacute;pez V, Ortiz AP, Soto-Salgado M, Torres-Cintr\u0026oacute;n M, Pettaway CA, Puras-B\u0026aacute;ez A, et al. Penile Cancer Disparities in Puerto Rican Men as compared to the United States Population. Int Braz J Urol. 2012 Nov 1;38(6):728\u0026ndash;37. doi:10.1590/1677-553820133806728\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Tamayo V, Scorsone A, Soto-Salgado M, Febo I, Piovanetti P, et al. Prevalence and correlates of cervical HPV infection in a clinic-based sample of HIV-positive Hispanic women. Papillomavirus Res. 2017 Dec 1;4:39\u0026ndash;44. doi:10.1016/j.pvr.2017.06.006\u003c/li\u003e\n\u003cli\u003eCol\u0026oacute;n-L\u0026oacute;pez V, Ortiz AP, Del Toro-Mej\u0026iacute;as LM, Garc\u0026iacute;a H, Clatts MC, Palefsky J. Awareness and knowledge of Human Papillomavirus (HPV) infection among high-risk men of Hispanic origin attending a Sexually Transmitted Infection (STI) clinic. BMC Infect Dis. 2012 Dec 12;12. doi:10.1186/1471-2334-12-346\u003c/li\u003e\n\u003cli\u003eCol\u0026oacute;n-L\u0026oacute;pez V, Ortiz AP, Palefsky J. Burden of human papillomavirus infection and related comorbidities in men: Implications for research, disease prevention and health promotion among hispanic men. P R Health Sci J. 2010;29(3):232\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eCol\u0026oacute;n-L\u0026oacute;pez V, Ortiz AP, Soto-Salgado M, Torres-Cintr\u0026oacute;n M, Mercado-Acosta JJ, Su\u0026aacute;rez E. Anal cancer incidence and mortality in Puerto Rico. P R Health Sci J. 2013;32(2):76\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eColon-Lopez V, Ortiz AP, Soto-Salgado M, Torres-Cintr\u0026oacute;n M, Perez N, Mercado-Acosta JJ, et al. Survival from anal cancer among Hispanics - Puerto Rico, 2000-2007. J Gastrointest Cancer. 2014;45(2):234\u0026ndash;8. doi:10.1007/s12029-014-9607-x\u003c/li\u003e\n\u003cli\u003eOrtiz AP, P\u0026eacute;rez-Irizarry J, Soto-Salgado M, Su\u0026aacute;rez E, P\u0026eacute;rez N, Cruz M, et al. Human papillomavirus-related cancers among people living with AIDS in Puerto Rico. Prev Chronic Dis. 2014;11(5):11\u0026ndash;6. doi:10.5888/pcd11.130361\u003c/li\u003e\n\u003cli\u003eRomaguera J, Caballero-Varona D, Tortolero-Luna G, Marrero E, Su\u0026aacute;rez E, P\u0026eacute;rez CM, et al. Factors associated with HPV vaccine awareness in a population-based sample of hispanic women in Puerto Rico. J Racial Ethn Heal Disparities. 2015;3(2):281\u0026ndash;90. doi:10.1007/s40615-015-0144-5\u003c/li\u003e\n\u003cli\u003eOrtiz AP, Soto-Salgado M, Calo WA, Tortolero-Luna G, P\u0026eacute;rez CM, Romero CJ, et al. Incidence and mortality rates of selected infection-related cancers in Puerto Rico and in the United States. Infect Agent Cancer. 2010;5(1):1\u0026ndash;10. doi:10.1186/1750-9378-5-10\u003c/li\u003e\n\u003cli\u003eHealthy People. Increase the percentage of female adolescents aged 13 through 15 years who receive 2 or 3 doses of human papillomavirus (HPV) vaccine as recommended [Internet]. Inmunization and Infectious diseases. [cited 2020 Jul 24]. Available from: https://www.healthypeople.gov/node/3527/objectives#4657\u003c/li\u003e\n\u003cli\u003eWalker TY, Elam-Evans LD, Singleton JA, Yankey D, Markowitz LE, Fredua B, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13\u0026ndash;17 Years \u0026mdash; United States, 2016. MMWR Morb Mortal Wkly Rep. 2017 Aug;66(33):874\u0026ndash;82. doi:10.15585/mmwr.mm6633a2\u003c/li\u003e\n\u003cli\u003eNational Immunization Survey- Teen. 2016 Adolescent HPV Vaccination Coverage Report [Internet]. Centers for Disease Control and Prevention. 2016 [cited 2018 Sep 24]. Available from: https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/reports/2016.html\u003c/li\u003e\n\u003cli\u003eCommunity Preventive Services Task Force. What Works Fact Sheet: Increasing Appropriate Vaccination [Internet]. The Community Guide. 2017 [cited 2020 Jun 1]. Available from: https://www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf\u003c/li\u003e\n\u003cli\u003eNational Conference of State Legislatures. HPV Vaccine: State Legislation and Statutes. 2017. Available from: https://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx\u003c/li\u003e\n\u003cli\u003eThompson EL, Livingston MD, Daley EM, Zimet GD. Human papillomavirus vaccine initiation for adolescents following Rhode Island\u0026rsquo;s school-entry requirement, 2010-2016. Am J Public Health. 2018;108(10):1421\u0026ndash;3. doi:10.2105/AJPH.2018.304552\u003c/li\u003e\n\u003cli\u003ePerkins RB, Lin M, Wallington SF, Hanchate AD. Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009\u0026ndash;2013 National Immunization Survey-Teen. Hum Vaccines Immunother [Internet]. 2016;12(6):1615\u0026ndash;22. doi:10.1080/21645515.2016.1150394\u003c/li\u003e\n\u003cli\u003eOmer SB, Richards JL, Ward M, Bednarczyk RA. Vaccination policies and rates of exemption from immunization, 2005-2011. N Engl J Med. 2012 Sep;367(12):1170\u0026ndash;1. doi:10.1056/NEJMc1209037\u003c/li\u003e\n\u003cli\u003eSalmon DA, Omer SB, Moulton LH, Stokley S, Dehart MP, Lett S, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health. 2005 Mar;95(3):436\u0026ndash;40. doi:10.2105/AJPH.2004.046201\u003c/li\u003e\n\u003cli\u003eSuppli CH, Hansen ND, Rasmussen M, Valentiner-Branth P, Krause TG, M\u0026oslash;lbak K. Decline in HPV-vaccination uptake in Denmark - The association between HPV-related media coverage and HPV-vaccination. BMC Public Health. 2018;18(1):1\u0026ndash;8. doi:10.1186/s12889-018-6268-x\u003c/li\u003e\n\u003cli\u003eTeoh D. The Power of Social Media for HPV Vaccination\u0026ndash;Not Fake News! Am Soc Clin Oncol Educ B. 2019;(39):75\u0026ndash;8. doi:10.1200/edbk_239363\u003c/li\u003e\n\u003cli\u003eKrueger R, Casey M. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications; 2009.\u003c/li\u003e\n\u003cli\u003eKelly BJ, Leader AE, Mittermaier DJ, Hornik RC, Cappella JN. 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 Nov;77(2):308\u0026ndash;13. doi:10.1016/j.pec.2009.03.018\u003c/li\u003e\n\u003cli\u003eC\u0026aacute;mara de Representantes. P. de la C. 1303 [Internet]. 2017 [cited 2020 Jun 7]. p. 1\u0026ndash;28. Available from: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf\u003c/li\u003e\n\u003cli\u003eGobierno de Puerto Rico. Ley de las Inmunizaciones Compulsorias a los Ni\u0026ntilde;os Pre-escolares y Estudiantes en el Estado Libre Asociado de Puerto Rico [Internet]. 2018 [cited 2020 Jul 24]. p. 1\u0026ndash;6. Available from: http://www.bvirtual.ogp.pr.gov/ogp/Bvirtual/leyesreferencia/PDF/Educaci\u0026oacute;n (K-12)/25-1983/25-1983.pdf\u003c/li\u003e\n\u003cli\u003eOubari H, Tuttle R, Rath B, Bravo L. Communicating Vaccine Safety to the Media and General Public. Curr Drug Saf. 2015;10(1):80\u0026ndash;6. doi:10.2174/157488631001150407111312\u003c/li\u003e\n\u003cli\u003eRousseau C, Moreau N, Dumas MP, Bost I, Lefebvre S, Atlani-Duault L. Public media communications about H1N1, risk perceptions and immunization behaviours: A Quebec\u0026ndash;France comparison. Public Underst Sci. 2015;24(2):225\u0026ndash;40. doi:10.1177/0963662513495149\u003c/li\u003e\n\u003cli\u003eHilton S, Hunt K, Langan M, Bedford H, Petticrew M. Newsprint media representations of the introduction of the HPV vaccination programme for cervical cancer prevention in the UK ( 2005 \u0026ndash; 2008 ). Soc Sci Med. 2010;70(6):942\u0026ndash;50. doi:10.1016/j.socscimed.2009.11.027\u003c/li\u003e\n\u003cli\u003eAbdelmutti N, Hoffman-Goetz L. Risk messages about HPV, cervical cancer, and the HPV vaccine Gardasil in North American news magazines. In: Journal of Cancer Education. Springer; 2010. p. 451\u0026ndash;6. doi:10.1007/s13187-010-0087-9\u003c/li\u003e\n\u003cli\u003eDunn AG, Leask J, Zhou X, Mandl KD, Coiera E. Associations between exposure to and expression of negative opinions about human papillomavirus vaccines on social media: An observational study. J Med Internet Res. 2015;17(6):e144. doi:10.2196/jmir.4343\u003c/li\u003e\n\u003cli\u003eMargolis MA, Brewer NT, Shah PD, Calo WA, Gilkey MB. Stories about HPV vaccine in social media, traditional media, and conversations. Prev Med (Baltim). 2019;118:251\u0026ndash;6. doi:10.1016/j.ypmed.2018.11.005\u003c/li\u003e\n\u003cli\u003eBriones R, Nan X, Madden K, Waks L. When Vaccines Go Viral: An Analysis of HPV Vaccine Coverage on YouTube. Health Commun. 2012;27(5):478\u0026ndash;85. doi:10.1080/10410236.2011.610258\u003c/li\u003e\n\u003cli\u003eKeelan J, Pavri V, Balakrishnan R, Wilson K. An analysis of the Human Papilloma Virus vaccine debate on MySpace blogs. Vaccine. 2010;28(6):1535\u0026ndash;40. doi:10.1016/j.vaccine.2009.11.060\u003c/li\u003e\n\u003cli\u003eHabel MA, Liddon N, Stryker JE. The HPV vaccine: A content analysis of online news stories. J Women\u0026rsquo;s Heal. 2009;18(3):401\u0026ndash;7. doi:10.1089/jwh.2008.0920\u003c/li\u003e\n\u003cli\u003eVazquez-Otero C. Understanding the adoption process of an HPV vaccine school-entry requirement in Puerto Rico. PhD dissertation. Vol. 23. University of South Florida; 2019.\u003c/li\u003e\n\u003cli\u003eCasciotti DM, Smith KC, Andon L, Vernick J, Tsui A, Klassen AC. Print news coverage of school-based human papillomavirus vaccine mandates. J Sch Health. 2014 Feb;84(2):71\u0026ndash;81. doi:10.1111/josh.12126\u003c/li\u003e\n\u003cli\u003eGollust SE, LoRusso SM, Nagler RH, Fowler EF. Understanding the role of the news media in HPV vaccine uptake in the United States: Synthesis and commentary. Hum Vaccin Immunother. 2016;12(6):1430\u0026ndash;4. doi:10.1080/21645515.2015.1109169\u003c/li\u003e\n\u003cli\u003eOdone A, Ferrari A, Spagnoli F, Visciarelli S, Shefer A, Pasquarella C, et al. Effectiveness of interventions that apply new media to improve vaccine uptake and vaccine coverage. Hum Vaccin Immunother. 2015 Jan 1;11(1):72\u0026ndash;82. doi:10.4161/hv.34313\u003c/li\u003e\n\u003cli\u003eLarson HJ, Wilson R, Hanley S, Parys A, Paterson P. Tracking the global spread of vaccine sentiments: The global response to Japan\u0026rsquo;s suspension of its HPV vaccine recommendation. Hum Vaccin Immunother. 2014;10(9):2543\u0026ndash;50. doi:10.4161/21645515.2014.969618\u003c/li\u003e\n\u003cli\u003eOkuhara T, Ishikawa H, Okada M, Kato M, Kiuchi T. Amount of narratives used on Japanese Pro- and Anti-HPV vaccination websites: A content analysis. Asian Pacific J Cancer Prev. 2018;19(10):2691\u0026ndash;4. doi:10.22034/APJCP.2018.19.10.2691\u003c/li\u003e\n\u003cli\u003eC\u0026aacute;mara de Representantes. P. de la C. 1576 [Internet]. 2018 [cited 2020 Jun 7]. p. 1\u0026ndash;7. Available from: http://www.ea-journal.com/images/stories/Art04.02/Pinto-et-al-Vacunacion-obligatoria-y-movimiento-anti-vacuna.pdf\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Content of the Online Media Articles Analyzed Regarding HPV Vaccine School-Entry Requirement: 2017-2018 (n=34 Articles)\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 59px;\"\u003e\n\u003ctd style=\"height: 59px;\" width=\"414\"\u003e\n\u003cp\u003e\u003cstrong\u003eTopics discussed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 59px;\" width=\"105\"\u003e\n\u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 59px;\" width=\"105\"\u003e\n\u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u003cem\u003eHPV-associated cancers\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Cervical cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e58.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Oropharyngeal cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e23.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Penile cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e20.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Vulvar/vaginal cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e20.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Anal cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e11.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eEffective date of mandate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e91.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eNumber of doses that are recommended for complete HPV vaccination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e38.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eConcerns about the efficacy and safety of the vaccine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e55.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eHighlighted the importance of the vaccine for cancer prevention\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e79.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eReferred to HPV as a STI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e26.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eInformation regarding HPV vaccine accessibility and health coverage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e23.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003eGroups Cited\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Coalitions Groups Against the Implementation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e32.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Government Agency Representatives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e85.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Health Professionals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e29.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Data and Statistics Institutes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e41.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Coalitions Groups In favor of the Implementation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e11.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"414\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Others\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"105\"\u003e\n\u003cp\u003e8.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Groups against the HPV vaccine school-entry requirement and their reasons.\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"479\"\u003e\n\u003ch3\u003eReason against HPV vaccine school-entry requirement\u003c/h3\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eFamily coalition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"479\"\u003e\n\u003cp\u003eThe vaccine only protects against the most common virus strains and questions its effectiveness.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eFeminist groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"479\"\u003e\n\u003cp\u003eDid not object to the vaccine but question the obligatory nature of the policy since the vaccine has been controversial. Recommend that it be accompanied by vaccine education and sex education. State that each family must decide freely in their health strategies.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eLocal coalitions against HPV school entry requirement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"479\"\u003e\n\u003cp\u003eViolates the rights of parents in deciding on the care of their children, and they have the right to be informed of the risks of any medical treatment. They understand that the government is obstructing education with this requirement given the high number of vaccines that are imposed annually as part of the school-entry policy and support of the 1576 bill\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Human papillomavirus, HPV Vaccine Implementation, School-Entry Policy Requirements, Content Analysis, Puerto Rico","lastPublishedDoi":"10.21203/rs.3.rs-67660/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-67660/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eIn August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11-12 years old. Evidence suggests that the content of media coverage may impact people's perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe search resulted in 34 articles in 17 online local and international news outlets that reported on the implementation of the policy. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eMost of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Content Analysis of Digital Media Coverage of the Human Papillomavirus Vaccine School-Entry Requirement Policy in Puerto Rico","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-09-10 18:18:22","doi":"10.21203/rs.3.rs-67660/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-04-22T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-09T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses a testable research question(s) (brief or other article types: is there a clear objective)?\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nNo - there are major issues\n\nEXECUTION - Are the experiments and analyses performed with technical rigor to allow confidence in the results?\nNo - there are major issues\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nNo - there are issues with the statistics in the study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nNo - there are major issues\n\nOVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically sound? If not, can revisions be made to make the work technically sound?\nMaybe - with major revisions\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS:\nThis manuscript reports interesting and important information to show how news media deliver positive, neutral, or negative messages about HPV vaccination in Puerto Rico. Their results may be useful to make policy regarding HPV vaccination requirement in other areas as well as PR. However, there are several main issues to be addressed to make the study accurate and sound (see below). The biggest concern is the small number of new articles in the narrow period of their publications, which is not sufficient to generate any meaningful results and solid conclusion.\n\nREQUESTED REVISIONS:\n\"HPV cause 91% of cervical cancers\" Almost all cervical cancers are known to be caused by HPV. Based on only one reference published in 2016, claiming the exact 91% sounds biased.\n\nHPV also causes head and neck cancer, which cases are dramatically increased recently. As head and neck cancer is also prevented the HPV vaccines, HNC should also be discussed along with cervical and other anogenital cancers.\n\nThe study included only 34 qualified articles. It is unclear that this number could provide any meaningful conclusion.\n\nThe alignment in Table 2 is confusing and difficult to read.\n\nThe shifted temporal patterns at two time points in Figure 2 are not useful and should include a few more points. It is also unclear why the study analyzed only two years. Also, the gray scale of the graph does not stratify different group well and should be replaced with additional patterns.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-04-05T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-01T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\n\nPlease overwrite this text when adding your comments to the authors.\n\nThank you for the opportunity to review \"Content analysis of digital media coverage of the human papilloma virus vaccine school-entry requirement policy in Puerto Rico.\" The study was well done and the manuscript is well written. The study describes the media environment prior to and during the rollout of mandatory HPV vaccination in Puerto Rico. My comments are minor and include:\n\nLine 165: \"legitimate news media outlets\" - can you delineate how you defined \"legitimate\"? Was there a criteria to be considered \"legitimate\"?\n\nResults:\n\nIf the most common type of results were neutral media sources, why start with Negative Media? It's the least frequent. Shouldn't the results section be organized by volume - Neutral, Positive, Negative? \n\nLine 276: The Cancer Prevention findings are listed in the Positive Media section, but the information presented seems neutral and factual. Please reconsider whether this should go in the Neutral findings.\n\nLines 289-298: This information about the legislation in PR is background and should go in the Background section, not in the results. \n\nLine 318: What is Law #25? A description of this can also go in the background section on legislation (see comment about lines 289-298)\n\n\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. 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Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **'I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-17T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-09-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-31T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-31T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-08-27T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39c187fb-5e63-46dc-a670-5f2e4ab8a53d","owner":[],"postedDate":"September 10th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":484816,"name":"Health Economics \u0026 Outcomes Research"},{"id":484817,"name":"Infectious Diseases"},{"id":484818,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-07-27T20:57:15+00:00","versionOfRecord":{"articleIdentity":"rs-67660","link":"https://doi.org/10.1186/s12889-021-11311-9","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2021-07-01 20:57:15","publishedOnDateReadable":"July 1st, 2021"},"versionCreatedAt":"2020-09-10 18:18:22","video":"","vorDoi":"10.1186/s12889-021-11311-9","vorDoiUrl":"https://doi.org/10.1186/s12889-021-11311-9","workflowStages":[]},"version":"v1","identity":"rs-67660","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-67660","identity":"rs-67660","version":["v1"]},"buildId":"qQ7_6M8ijIrYJ9CiyUnPg","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}