Online media use and HPV vaccination intentions in mainland China: integrating marketing and communication perspectives to improve public health

Online media use and HPV vaccination intentions in mainland China: integrating marketing and... Abstract This study investigates the role of media in shaping human papilloma virus vaccination intentions in mainland China by applying both communication and marketing-focused theoretical frameworks in order to better understand ways to increase vaccine uptake across young men and women in China. An online survey (N = 359) revealed direct effects of online information consumption on perceived scarcity of the vaccine, as well as an indirect effect via perceived influence of media on others. Scarcity perceptions, in turn, predicted vaccine attitudes and behavioral intentions. Additionally, gender differences emerged in the data. Compared with women, men’s intent to be vaccinated were not high, even if they realized the vaccine shortage. Implications for theory and practice are discussed. Introduction The human papilloma virus (HPV) is a sexually transmitted infection that can cause cancer, which led scientists to eventually develop a vaccine for it [1]. Although individuals in western countries have had access to the vaccine for some time, people in mainland China had to wait for the arrival of the HPV vaccine [2]. Not until July of 2016 did the China Food and Drug Administration (CFDA) approve the 2-valent HPV vaccine, which is capable of protecting against two strains of HPV [3]. One year later, the 4-valent vaccine was made available in mainland China. Eventually, CFDA sped up the approval process for the 9-valent vaccine, which was conditionally approved to enter the Chinese market in 2018. Given the vaccine has only recently been available there, many people in China may be not as well educated about HPV or the HPV vaccine as western audiences [4]. Work by Zhang et al. [5] indicates that many Chinese citizens are confused about the differences between types of HPV vaccines, where they can make an appointment to receive the vaccine, and how much the vaccine will cost them. This lack of knowledge may explain why cervical cancer is a leading cause of cancer-related death in China, despite being largely preventable via vaccination [6]. Since the HPV vaccine is relatively new for residents of mainland China, and residents of the country have expressed a desire for more information about it, individuals are likely turning to the Internet to seek information about the HPV vaccine. According to Habel et al. [7], during the early stage of the HPV vaccine’s introduction, ‘[the online news articles] may have consisted of more basic factual information rather than depicting controversies.’ (p. 405) Indeed, an examination of news coverage of the HPV vaccine in mainland China suggests that a considerable focus of these news stories is factual information, particularly about market factors, such as price and availability. The vaccine is high priced in China [8]. Chinese individuals have to pay more than 300 US dollars out of pocket for three doses of the Gardasil 9 vaccine as it is not covered under China’s medical insurance [9]. One news article from China Daily revealed that there are not enough of Gardasil 4 being manufactured in order to meet mainland people’s demand [10]. Due to its limited quantity in the domestic market, Chinese consumers have to make reservations months in advance in order to secure a vaccination [11]. As such, many young women traveled to Hong Kong or neighboring countries to get vaccinated [9]. Their eagerness to buy the vaccine has even facilitated some related services on e-commerce websites such as Taobao [12]. Not only can these online sellers help their customers reserve the vaccine in Hong Kong’s health centers, but they also help them manage their travel schedules for the series of three injections. In addition to online news content about the HPV vaccine, Chinese consumers can also find information from social media platforms. A search on Chinese popular social media platforms, such as Weibo, Zhihu and Red Book (‘Xiao Hong Shu’ in Chinese), reveals a great deal of user-generated content about the HPV vaccine. For instance, many messages are about tips and guides about how to get the HPV vaccine. While searching the keywords ‘the HPV vaccine’ on Red Book, an online community combined with e-commerce services, more than 3000 results emerged. Given the consumer focus of the community, their members appear to regard the vaccine as a luxury item and a scarce commodity. Overall, examinations of online information have suggested that the HPV vaccine is welcome but expensive and scarce in mainland China. These messages may serve to further amplify viewers’ perceived scarcity of the vaccine, which could in turn influence their attitudes and intentions regarding the HPV vaccine. As such, the present study examines the relationships between mainland Chinese’s online information consumption and vaccination intentions. Importantly, we ground our analyses in two theoretical traditions: cultivation analysis [13] and the influence of presumed influence model (IPI model [14]). Together, these approaches allow for a more nuanced understanding of how exposure to online content can shape vaccination intentions. And, unlike prior works that discussed HPV vaccination as a health issue alone, due to the media coverage of the vaccine as a scarce commodity in China, our study also included an examination of the role of scarcity, an important variable from a commodity marketing standpoint. In addition, we questioned if gender differences occurred in perceptions of the vaccine, an important investigation given the often genderized nature of HPV vaccination. Overall, the study provides a better understanding of the factors behind HPV vaccination rates across genders in mainland China and sheds light on the impact of online information exposure on HPV vaccine-related perceptions and intentions. The results presented here can be applied to improve public outreach efforts aimed at young adults in China. Literature review Below, we offer an overview of the conceptual frameworks that guided our study on the role of online media use in shaping Chinese individual’s intentions to vaccinate against HPV. Scarce is good Unlike in the United States, the HPV vaccine is not readily available in mainland China. In considering the role of market forces in shaping responses to HPV vaccine information, a good starting point is understanding the effects of scarce commodities. A commodity is simply anything that is exchangeable and useful to consumers [15]. These include messages, experiences, physical objects and even skills. Advertisers have noticed that consumers often desire commodities that other people want, too. For instance, we can see advertisements that note ‘while supplies last’ or ‘limited time offer’. Research suggests that limited-quantity messages are more persuasive than limited-time messages, though [16]. Scarcity appeals in commercial messages are an efficient strategy to trigger consumers’ value perception of the product (see Ref. [17], for a review). Developed by Brock [18], commodity theory suggests that consumers’ perceived value of a commodity is influenced by its degree of unavailability, especially if they have information that ‘implies that obtaining a resource will be costly in terms of time, effort, and/or money’ [19, p. 5]. In other words, the more limited and resource-intensive the commodity is, the more valuable it is in the eyes of consumers. One psychological explanation of consumers’ desire for rare goods is their need for uniqueness [20]. Owning resources that only a few others possess is an easy way to signal their superior social status. In addition to value perception, cognitive evaluation is also an often-tested outcome variable related to scarcity. For instance, Gierl and Huettl [21] examined the interactive effect of types of scarcity and types of products on persuasion. Their research revealed that when people’s chances of owning a product are reduced due to high demand, they are more likely to have positive product attitudes. Because value perceptions and attitudes can be influenced by messages emphasizing the scarcity of a commodity, it is possible that commodity theory may help explain how messages discussing scarcity help predict intentions to secure a vaccine—a commodity. Cultivation theory While perceived product scarcity is a key variable that may explain vaccine attitudes and behavior in mainland China, another vital factor is information exposure. Examining the role of information exposure, or media use, more broadly as a predictor of vaccination perceptions and intentions leads us to a discussion of cultivation theory. Proposed by Gerbner et al. in 1976, cultivation theory examines the relationship between audiences’ television viewing and evaluation of the world [22]. The core argument of cultivation theory is that compared with light viewers, people who watch television frequently are more likely to internalize the messages and themes from television and believe them to be reflective of the real world [23]. Cultivation analysis initially concentrated on the effects of overall television viewing [22], but has extended to non-television genres, such as online games (e.g. [24]) and social media (e.g. [25]). The present study focuses on Chinese individual’s consumption of online media content regarding the HPV vaccine for several reasons. First, the Internet provides citizens with a high-speed communication environment [26] where they can quickly get the most recent information about new products and technologies, including vaccinations. Thus, it is reasonable to presume that mainland Chinese rely on the Internet to help them understand the HPV vaccine, which is only newly available in this part of the world. Second, HPV vaccination is discussed in this study from a market perspective. We are interested in people’s estimate of demand and supply for the HPV vaccine in mainland China and their attitudes (positive versus negative) toward the vaccine, as these factors can influence behavioral intentions. Social media and the Internet are likely to offer information in which the vaccine is regarded as commodities, thereby shaping scarcity perceptions. For instance, mainland Chinese consumers can make vaccination appointments online and view vaccine product reviews on social media. Under these considerations, therefore, we believe that it would be more appropriate to examine mainland Chinese’s exposure to online content regarding the HPV vaccine than television consumption. In short, people rely on information from the media to understand and think about the world around them. The perception of social reality stored in one’s memory can subsequently affect decision making and behavior. Cultivation theory focuses on the relationship between media exposure and people’s beliefs and worldviews, and as we argue, may help explain why sustained use of online information may help shape mainland Chinese perceptions of how scarce the HPV vaccine is. However, cultivation theory alone does not directly explore the relationship between media exposure and subsequent behaviors. Nabi and Sullivan [27], however, offer guidance for combining cultivation-related concepts with the classical components of Theory of Reasoned Action (developed by Fishbein and Ajzen [28]): attitude, behavioral intention and volitional behavior. Consistent with their hypotheses, Nabi and Sullivan found that heavy television viewers have stronger beliefs about the prevalence of crime and violence in society than light viewers. Those beliefs were positively correlated with opinions that ‘the world is a mean place’, which in turn predicted viewers’ intentions and engagement in protective actions. A direct effect of television viewing on intentions to take protective actions was also found. Based on how cultivation relates to attitudes and behaviors, as well as on the aforementioned literature noting the effects of scarcity perceptions on values and attitudes, we hypothesize that people in mainland China who are heavily exposed to vaccine-related online messages will have a stronger scarcity perception of the HPV vaccine, which in turn will predict their positive vaccine attitudes and intentions. In mainland China, H1: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positively related to vaccination intentions. H2: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positive related to perceived scarcity of the vaccine. H3: Higher levels of perceived scarcity of the HPV vaccine will be positively related to (i) attitudes toward the vaccine, and (ii) vaccination intentions via vaccine attitudes. Influence of presumed influence When examining media effects related to HPV vaccine messages in mainland China, another potential influence of messages discussing the scarce supply of the vaccine is that they may motivate consumers to think about how vaccine messages are also affecting others. That is, we should consider how online information about the HPV vaccine in mainland China influences Internet users’ perceptions that other people may be influenced by these vaccine-related messages. Theoretically, the notion of ‘presumed influence’ can help guide predictions as to the effects of scarcity in this realm. The IPI model, developed by Gunther and Storey [14], is derived from third-person effects (TPEs) research, which argues that people perceive a greater communication influence on others than on themselves [29]. Whereas individuals often do not believe they are directly influenced by media, they tend to believe people are, indeed, influenced by the messages around them. The underlying mechanism of TPEs can be explained by observers’ beliefs that they are different from others, but in a good way. When consuming media messages about negative consequences (e.g. binge drinking), people are confident in their abilities to avoid media influence, but they tend to overestimate others’ susceptibility to them [30, 31]. Unlike the TPEs model, which examines the discrepancy between perceived influence on self and others, the IPI model addresses how people’s perceived communication influence on others directly affects their reactions to the social reality [14]. It consists of four necessary steps: ‘self-exposure—other-exposure—presumed influence on others—own behavior’ [32, p. 471]. Specifically, the more time people spend consuming specific media messages, the more likely they are to believe that other people are also frequently exposed to similar content. This belief of others’ frequent exposure then leads to speculation that others are strongly influenced by that media exposure, which subsequently impacts the individual’s own attitudes and behaviors. According to the IPI model, because people are social in nature, thinking about how others are influenced by media should, in turn, influence our own reactions to media messages. Using the IPI model as a theoretical framework, the indirect effect of media on behavior has been tested in several empirical studies (e.g. [33–35]). In the Chinese context, Jiang and Chia [36] examined the effects of advertising exposure on young adults’ materialism. Their study found that Chinese individuals who frequently watched advertisements were very likely to perceive stronger media influence on their friends, which in turn increased their perceptions that their friends were more materialistic, which then drove up their own materialistic values. A desire to fit in with the perceived social trend likely led them to develop a higher level of materialism. The IPI model is also an important conceptual framework for the present study as it has been applied to scarcity-related messages. Sharma and Roy [37] looked into how scarcity appeals ‘promote a herd mentality and encourage bandwagon behavior’ (p. 83) from the perspective of IPI. They found that respondents’ value perception of a consumer product affected both perceived advertising influence on others and self, respectively. The path between perceived influence on others and purchase intention was mediated by perceived influence on self. That is, it was the participants’ belief that advertising influenced other individuals that, in turn, predicted their own perceived vulnerability toward advertisements and their eventual intention to purchase the product. Based on the IPI model and existing research applying it to the Chinese context and to scarcity-based messages, we offer the following hypotheses: In mainland China, H4: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positively related to perceived other-exposure to these messages. H5: Higher levels of respondents’ perceived other-exposure to online content regarding the HPV vaccine will be positively related to their perceived influence on others. H6: Higher levels of respondents’ perceived influence on others will be positively related to perceived scarcity of the vaccine. Other considerations In addition to the theoretically derived variables discussed above, it is possible that characteristics of the media users and their backgrounds may elsewise influence responses to the HPV vaccine in mainland China. Below we discuss the potential roles of gender, age, education and income levels in shaping user responses to Internet-based vaccine information in mainland China. Gender differences Although the HPV vaccine has been recommended for both boys and young adult men, the immunization rate for males is lower than for females in the United States [38]. One study by Nan [39] found that in the United States, female undergraduate students are more willing to take the vaccine than are male undergraduates. Additionally, males’ knowledge of the vaccine is relatively limited [40]. One explanation of the gender difference is that ‘public health campaigns have given out the wrong signals that the HPV vaccine is only useful to females’ [41]. Although the data on men versus women HPV vaccine use in China is not yet available, there are some clues from media coverage suggesting that gender differences may exist. Much Chinese newspapers’ coverage of the HPV vaccine stresses the importance of HPV vaccination in preventing women from cervical cancer [42], which is one of the most common cancers diagnosed among Chinese women. However, little media coverage suggests that men should also be vaccinated. Given all these factors, we ask if the women in our sample will have different perceptions of the HPV vaccine than men: RQ1: Will the data fit the model differently for men versus women? Age, education and income Age, educational background and income could also influence many of the perceptions that result in vaccination intentions. In mainland China, different types of HPV vaccines are recommended for different age groups. For instance, Cervarix is recommended for women aged 9–25, while Gardasil 4 is recommended for women aged 20–45 [43]. When it comes to educational background, prior research indicates that the relationship between education level and perceived acceptability of the HPV vaccine is not consistent (see [44], for a review). Jain et al. [45] found that people with an undergraduate degree or more education reported a higher awareness of the vaccine. However, some studies found that lower educational levels are associated with positive attitudes toward the HPV vaccine (e.g. [46]). Income, one dimension of socioeconomic status, may also impact vaccine attitudes and intentions. A positive correlation between parental income and vaccine acceptability was found in prior studies (e.g. [46]). Notably, the HPV vaccine is not free in mainland China and can be quite expensive [47]. It costs more than three hundred US dollars for the three required doses, not mentioning the extra transportation expense if people need to get the vaccine overseas or in Hong Kong. This makes the vaccine difficult to procure for low-income individuals in China [8]. Thus, in addition to the previous hypotheses, we plan to control for age, education and income in the present study. Figure 1 displays the conceptual model that combines the hypotheses and research questions into an overarching model. Fig. 1. Open in new tabDownload slide Conceptual model with hypotheses. Fig. 1. Open in new tabDownload slide Conceptual model with hypotheses. Materials and methods Participants We recruited mainland Chinese adults aged 18–45 to participate in this study. Although the HPV vaccine in China is accessible to people aged 9–45, our study did not recruit adolescents because their perceptions of health issues can be significantly influenced by their parents [48]. Furthermore, given the high cost of the vaccine in China, adolescents are less likely to get the vaccine without parental support and financing. Four hundred and twenty-four respondents were recruited from Wen Juan Xing (a Chinese data collection website) using a sample service. Each respondent was thanked and gained one US dollar compensation after completing the survey. Since one of our outcome variables is vaccination intentions, those who have already received an HPV vaccine (n = 65) were excluded, leaving a final sample size of 359. The average age of the respondents was 24.69 years old (SD = 3.55). The ages of respondents ranged from 18 to 33. About two-thirds (n = 240) of the respondents are women and 119 (33.10%) are men. Regarding educational background, 300 (83.60%) respondents’ highest education level to date is the bachelor’s degree; 28 (7.80%) of them are graduate students; 28 (7.8%) of them gained a high school diploma or equivalent; 3 (0.80%) respondents’ highest education degree is a middle school diploma. In terms of income, 48 (13.40%) respondents’ monthly household income was more than 15 000 CNY (Chinese yuan); 65 (18.10%) reported income of 12 000–15 000 CNY; 80 (22.30%) reported income of 9000–12 000 CNY per month; 65 (18.10%) reported income of 6000–9000 CNY per month; 81 (22.60%) reported income of 3000–6000 CNY per month; and 20 (5.60%) reported earning less than 3000 CNY monthly. Notably, the Chinese urban household’s income per capita for 2018 was 39 250.8 CNY [49]. Measures In the questionnaire, we measured self-exposure to online content related to the HPV vaccine, perceived other-exposure, perceived influence on others, perceived scarcity, vaccine attitudes, vaccination intentions and demographic information. Given that our respondents are Chinese citizens who may not understand English, a native mandarin speaker translated the questionnaire into Simple Chinese prior to distribution. All means and standard deviations are reported in Table I. Table I. Partialcorrelation between model variables Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Note: All partial correlations control for gender, age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Table I. Partialcorrelation between model variables Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Note: All partial correlations control for gender, age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Based on Gunther et al. [34], we used four items to measure media self-exposure, i.e. ‘In the recent period, how often have you seen HPV vaccine-related news on the internet’, “how often have you seen HPV vaccine-related content in social media, such as Weibo, WeChat, Red Book’, “how often have you seen HPV vaccine-related online discussions’ and ‘how often have you searched for HPV vaccine-related information on the internet’. The answer options were never (1), rare, sometimes, often or always (5). All items comprised a composite index for the variable of self-exposure. To get the average score, we cumulated the points received from each item and divided them by the total amount of items. The scale demonstrated good internal consistency (Cronbach’s α = 0.85). The perception of other-exposure was also treated as a composite variable and measured by four items, i.e. ‘how likely do you think that others have been reviewing HPV vaccine-related news on the internet’, ‘others have been reviewing HPV vaccine-related content in social media, such as Weibo, WeChat, Red Book’, ‘others have been reviewing HPV vaccine-related online discussions’. The answer options for these items ranged from very unlikely (1) to very likely (7). We also asked respondents to respond to an item drawn from Jiang and Chia [36] ‘to which degree do you think that others have been paying attention to online content related to the HPV vaccine’ with answer options ranged from never paid attention (1) to paying lots of attention (7). The scale demonstrated good internal consistency (Cronbach’s α = 0.88). To measure perceived influence on others, one seven-point scale item was employed, i.e. ‘to which degree do you think these online messages have influenced the opinions of other viewers toward the vaccine’ [50]. To assess perceived scarcity of the HPV vaccine in mainland China, respondents were asked ‘to which extent do you agree that the HPV vaccine is rare in mainland China’, ‘to which extent do you agree that the HPV vaccine demand exceeds its supply in the domestic market’ and ‘to which extent do you agree that due to short supply many people tried to get the vaccine outside the country’ using seven-point answer options from strongly disagree to strongly agree. The internal consistency of the scale is good (Cronbach’s α = 0.84). Attitude toward the HPV vaccine [51] was measured using a seven-point semantic differential single-item scale. That is, respondents were asked, ‘I think the HPV vaccine is bad/good’. Vaccination intention [52] was also measured using one single item, i.e. ‘In the near future, how likely would you take the vaccine’ with answer options ranged from very unlikely (1) to very likely (5). We developed a set of items to ascertain demographic information about respondents’ gender, age, education background and monthly family income. Specifically, we asked respondents about gender, i.e. male/female, age (open-ended question), and their highest degree of education they have received so far (the answer options contain middle school diploma, high school diploma, bachelor’s degree, master’s degree, doctoral degree and post-doctoral degree). Regarding income, respondents were asked ‘how much is your household income per month’ with answer options ranged from less than 3000 to 15 000 CNY or more. Table I shows the partial correlation between model variables after controlling for demographic variables, i.e. gender, age, education and income that might affect vaccine attitudes and intentions. Results To address the hypotheses, we performed a path analysis using SPSS Amos 25. After controlling for gender, age, education level and monthly income (i.e. we allowed each of these control variables to predict each of the variables in the conceptual model), the model demonstrated acceptable fit: χ2 = 23.26, df = 7, P < 0.01; CFI = 0.972; RMSEA = 0.081 (PCLOSE = 0.071; 90% confidence interval = 0.046 to 0.118); SRMR = 0.032. Given that the chi-square goodness-of-fit test is sensitive to sample size, we are not surprised that the P-values was significant given that larger samples (e.g. over 200 respondents) frequently result in a χ2 at P < 0.05 [53]. The standardized path coefficients and their significance values were used to test the hypotheses. Specifically, respondents’ self-exposure to online content regarding the HPV vaccine is directly related to their intentions to be vaccinated (β = 0.20, P < 0.001). H1 was supported. With regard to cultivation effects, higher levels of self-exposure to online content regarding the HPV vaccine is a positive predator of perceived scarcity of the vaccine in mainland China (β = 0.31, P < 0.001). Hypothesis 2 was supported. The scarcity perception, in turn, is positively related to respondents’ attitudes toward the vaccine (β = 0.17, P < 0.01). In other words, people who perceived the HPV vaccine as scarce and rare in mainland China tend to have positive vaccine attitudes. H3a was supported. In addition, perceived scarcity of the HPV vaccine in China is positively related to vaccine attitude, which in turn enhance intentions to be vaccinated (β = 0.17 * 0.22 = 0.04). The indirect effect is significant in the model vis 2000 bootstrap samples (P < 0.01). Regarding the IPI, higher levels of respondents’ self-exposure to online content regarding the HPV vaccine is positively related to perceived other-exposure to these messages (β = 0.45, P < 0.001). H4 was supported. The perception of other-exposure significantly increase respondents’ perceived media influence on others (β = 0.52, P < 0.001), which in turn increase their perceived scarcity of the vaccine (β = 0.17, P < 0.001). H5 and H6 were supported. To sum up, all of the hypothetical paths in the model are significant and in the expected direction (see Fig. 2). Fig. 2. Open in new tabDownload slide Path analysis results after controlling for gender, age, education and income. Parameters are standardized coefficients. *P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001. Fig. 2. Open in new tabDownload slide Path analysis results after controlling for gender, age, education and income. Parameters are standardized coefficients. *P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001. RQ1 asked whether the data fit the model differently for men versus women. To answer this question, we performed a multiple group path analysis to examine how the path for the female group differs from the path for the male group. First, we ran an unconstrained model that allowed all estimates for males and females to differ. After controlling for age, education and monthly income, the overall fit of the unconstrained model was good: χ2 = 29.91, df =14, P < 0.01; CFI = 0.968; RMSEA = 0.056 (PCLOSE = 0.319; 90% confidence interval = 0.028 to 0.084); SRMR = 0.035. As expected, the model fits better for women. All of the paths for the female group are significant, while some paths for the male group are nonsignificant (see Table II). Next, we ran a constrained model with all of the regression weights set to be equal for men and women. Compared with the unconstrained model, the constrained model resulted in a nonsignificant increase in test difference, Δχ2 = 31.898, df = 23, P = 0.102. This means that, overall, the model did not fit the data differently for women versus men. However, the possibility remained that there could be differences on the path level. As such, we reviewed the critical ratios for the unconstrained model (where paths were allowed to differ between men and women). These values revealed that the path linking vaccine attitude and intention was different between men and women. Hence, we ran another model that solely constrained this path and compared the difference between it and the unconstrained model. This test demonstrated that constraining this particular path results in a significantly worse fit, Δχ2 = 4.250, df = 1, P = 0.039. That is, the path vaccine attitude → vaccination intention is significantly different for women than men. Table II. Unstandardized path coefficient estimates and their significance tests . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* Note: Control for age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Table II. Unstandardized path coefficient estimates and their significance tests . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* Note: Control for age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Discussion The results presented above largely supported our hypotheses and give credence to incorporating an interdisciplinary perspective to understand why individuals in a country with a scarce supply of the HPV vaccine seek it out. To start, the data revealed that higher levels of respondents’ self-exposure are positively related to intent to be vaccinated. People who are frequently exposed to online content regarding the HPV vaccine are more willing to take the vaccine in comparison with light viewers. One potential explanation, which has been supported by Li et al.’s [42] content analysis, is that Chinese newspapers generally frame the vaccine in a favorable tone. Additionally, the results revealed the influence of online message viewing on vaccine intentions via scarcity perceptions and vaccine attitudes, which supports the cultivation effect on the attitude–intention relationship. Specifically, we found that viewing online media is positively related to respondents’ perceived scarcity of the HPV vaccine. The finding resonates with the cultivation theory by Gerbner and Gross [13] in which people who heavily watch television tend to believe what the medium tell them. There is a significant proportion of online news and consumer-generated content noting the HPV vaccine shortage on the mainland. As a result, people who are heavily exposed to these messages are very likely to regard the vaccine as a valuable commodity as not everyone is capable of owning it. From a marketing perspective, this finding suggests that using scarcity appeals may be an effective communication strategy for promoting the HPV vaccine in mainland China. Moreover, scarcity perceptions mediated the relationship between self-exposure and attitude toward the vaccine. In other words, people who are frequently exposed to vaccine messages are likely to believe that the vaccine is in short supply and thereby develop positive attitudes toward it. Given that a commodity’s unavailability can enhance value perceptions [18], it makes sense that scarcity perceptions and vaccine attitudes are positively correlated. On the other hand, however, the finding implies that when people spend most of their attention on how to get a vaccine that focus may reduce critical analyses of the vaccine effectiveness. As expected, and in line with the IPI model [14], our study revealed an indirect effect of online information consumption on scarcity perceptions via perceived influence of media on others. People who heavily view online content regarding the HPV vaccine tend to develop a stronger scarcity perception, as they believe that others also consume a lot of such content and develop a higher susceptibility to persuasion. This finding is consistent with Davison [29], who wrote that ‘there are always some people who will rush to the stores the moment when they hear reports of any possible shortage’. The reason is that they perceive a great impact of these messages on others and ‘want to stock up before the hoarders remove all goods from the shelves’ (p. 13). Given the fact that China has a large population that places a burden on resources, everyone’s basic needs cannot always be met, including vaccination. When Chinese people perceive that others are very vulnerable to vaccination messages, our data suggest that they tend to envision that others must work hard to purchase it, which may make the vaccine shortage worse. Perceived scarcity may generate a sense of insecurity and anxiety, causing people to desire the vaccine even more. Future research could investigate whether or not insecurity and anxiety result when Chinese people perceive the scarcity of the HPV vaccine to be high, and how these feelings influence vaccination intentions. In addition, this finding could reflect health disparity across nations. The higher level of self-exposure to online content regarding the vaccine has a positive correlation with scarcity perception via presumed influence on others. However, this would be unlikely to happen in developed countries where people can get the subsidized HPV vaccine at many locations. Unlike mainland Chinese individuals, who are worried about the vaccine’s unavailability, people in developed countries appear to have more safety concerns about the vaccine. It is worth noting that, according to Chen [54], the biggest HPV vaccine consumers in mainland China are ‘young, urban, middle-class women’, which is quite different from developed countries that market to young adolescents between the ages of 9 and 14 years old [3]. These cross-cultural differences point to the importance of conducting additional research in this area that directly compares media effects across countries. This study also examined important gender differences. The multiple group analysis results showed that the model fits better for women than for men. For the female group, all of the hypothetical paths are significant and in the expected direction. Yet for the male group, paths involved with vaccine attitudes or intentions are no longer significant. In other words, women who have positive attitudes toward the HPV vaccine tend to have higher intentions to be vaccinated. For the male group, however, positive vaccine attitude does not necessarily predict intentions. The finding is consistent with Nan [39], which also found willingness to get the HPV vaccine is relatively low among male college students. Also, we can see that the relationship between self-exposure and scarcity perceptions is more evident for Chinese women than men. As such, scarcity appeals may be better targeted toward female audiences. Chinese men might perceive these vaccine-related content differently. Future research could use additional variables, perhaps including social norm perceptions related to other men’s acceptance of vaccination, to better predict men’s reactions to online vaccine information. While the aforementioned results make many contributions to the literature, there are also several limitations to the study that must be mentioned. First, the convenience sample included twice as many women as men. Additional research should try to recruit more men. Second, some variables (i.e. presumed influence on others, vaccine attitude and intention) were measured using a single item, and future research with a longer questionnaire could help improve the internal validity of these items. Third, given the positive correlation between online media use and vaccination intentions, we speculate based on anecdotes that the vaccine-related content on the Internet in China is mostly framed in a positive and benefiting tone, but that is not known for sure. Additional content analyses of vaccine-related online information in mainland China, especially work that can compare and contrast information from news, government, and user-generated sources, are needed to help assess how the nature of online content may more specifically influence vaccine perceptions and intentions. Conclusion In conclusion, the present study integrated a market-based approach with previously applied conceptual models to better understand how online media use can shape HPV vaccination perceptions and intentions in mainland China. The findings point to the importance of understanding the commodity status and scarcity perceptions of a health-related product as part of the larger issue of understanding the interplay between media use and health behaviors. Future work can build of the findings presented here to help develop campaigns and health interventions aimed at educating and facilitating HPV vaccination in mainland China and in other countries where the vaccine is scarce. Conflict of interest statement The authors have no conflict of interests to declare. This article was presented at 2019 AEJMC, Toronto. References 1 Castellsagué X. Natural history and epidemiology of HPV infection and cervical cancer . Gynecol Oncol 2008 ; 110 : S4 – 7 . 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China: how access to the HPV vaccine entrenches China’s health care gap, 21 May 2018 . Available at: https://www.sixthtone.com/news/1002308/how-access-to-the-hpv-vaccine-entrenches-chinas-health-care-gap. Accessed: 18 November 2019. © The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Education Research Oxford University Press

Online media use and HPV vaccination intentions in mainland China: integrating marketing and communication perspectives to improve public health

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Oxford University Press
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© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
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Abstract

Abstract This study investigates the role of media in shaping human papilloma virus vaccination intentions in mainland China by applying both communication and marketing-focused theoretical frameworks in order to better understand ways to increase vaccine uptake across young men and women in China. An online survey (N = 359) revealed direct effects of online information consumption on perceived scarcity of the vaccine, as well as an indirect effect via perceived influence of media on others. Scarcity perceptions, in turn, predicted vaccine attitudes and behavioral intentions. Additionally, gender differences emerged in the data. Compared with women, men’s intent to be vaccinated were not high, even if they realized the vaccine shortage. Implications for theory and practice are discussed. Introduction The human papilloma virus (HPV) is a sexually transmitted infection that can cause cancer, which led scientists to eventually develop a vaccine for it [1]. Although individuals in western countries have had access to the vaccine for some time, people in mainland China had to wait for the arrival of the HPV vaccine [2]. Not until July of 2016 did the China Food and Drug Administration (CFDA) approve the 2-valent HPV vaccine, which is capable of protecting against two strains of HPV [3]. One year later, the 4-valent vaccine was made available in mainland China. Eventually, CFDA sped up the approval process for the 9-valent vaccine, which was conditionally approved to enter the Chinese market in 2018. Given the vaccine has only recently been available there, many people in China may be not as well educated about HPV or the HPV vaccine as western audiences [4]. Work by Zhang et al. [5] indicates that many Chinese citizens are confused about the differences between types of HPV vaccines, where they can make an appointment to receive the vaccine, and how much the vaccine will cost them. This lack of knowledge may explain why cervical cancer is a leading cause of cancer-related death in China, despite being largely preventable via vaccination [6]. Since the HPV vaccine is relatively new for residents of mainland China, and residents of the country have expressed a desire for more information about it, individuals are likely turning to the Internet to seek information about the HPV vaccine. According to Habel et al. [7], during the early stage of the HPV vaccine’s introduction, ‘[the online news articles] may have consisted of more basic factual information rather than depicting controversies.’ (p. 405) Indeed, an examination of news coverage of the HPV vaccine in mainland China suggests that a considerable focus of these news stories is factual information, particularly about market factors, such as price and availability. The vaccine is high priced in China [8]. Chinese individuals have to pay more than 300 US dollars out of pocket for three doses of the Gardasil 9 vaccine as it is not covered under China’s medical insurance [9]. One news article from China Daily revealed that there are not enough of Gardasil 4 being manufactured in order to meet mainland people’s demand [10]. Due to its limited quantity in the domestic market, Chinese consumers have to make reservations months in advance in order to secure a vaccination [11]. As such, many young women traveled to Hong Kong or neighboring countries to get vaccinated [9]. Their eagerness to buy the vaccine has even facilitated some related services on e-commerce websites such as Taobao [12]. Not only can these online sellers help their customers reserve the vaccine in Hong Kong’s health centers, but they also help them manage their travel schedules for the series of three injections. In addition to online news content about the HPV vaccine, Chinese consumers can also find information from social media platforms. A search on Chinese popular social media platforms, such as Weibo, Zhihu and Red Book (‘Xiao Hong Shu’ in Chinese), reveals a great deal of user-generated content about the HPV vaccine. For instance, many messages are about tips and guides about how to get the HPV vaccine. While searching the keywords ‘the HPV vaccine’ on Red Book, an online community combined with e-commerce services, more than 3000 results emerged. Given the consumer focus of the community, their members appear to regard the vaccine as a luxury item and a scarce commodity. Overall, examinations of online information have suggested that the HPV vaccine is welcome but expensive and scarce in mainland China. These messages may serve to further amplify viewers’ perceived scarcity of the vaccine, which could in turn influence their attitudes and intentions regarding the HPV vaccine. As such, the present study examines the relationships between mainland Chinese’s online information consumption and vaccination intentions. Importantly, we ground our analyses in two theoretical traditions: cultivation analysis [13] and the influence of presumed influence model (IPI model [14]). Together, these approaches allow for a more nuanced understanding of how exposure to online content can shape vaccination intentions. And, unlike prior works that discussed HPV vaccination as a health issue alone, due to the media coverage of the vaccine as a scarce commodity in China, our study also included an examination of the role of scarcity, an important variable from a commodity marketing standpoint. In addition, we questioned if gender differences occurred in perceptions of the vaccine, an important investigation given the often genderized nature of HPV vaccination. Overall, the study provides a better understanding of the factors behind HPV vaccination rates across genders in mainland China and sheds light on the impact of online information exposure on HPV vaccine-related perceptions and intentions. The results presented here can be applied to improve public outreach efforts aimed at young adults in China. Literature review Below, we offer an overview of the conceptual frameworks that guided our study on the role of online media use in shaping Chinese individual’s intentions to vaccinate against HPV. Scarce is good Unlike in the United States, the HPV vaccine is not readily available in mainland China. In considering the role of market forces in shaping responses to HPV vaccine information, a good starting point is understanding the effects of scarce commodities. A commodity is simply anything that is exchangeable and useful to consumers [15]. These include messages, experiences, physical objects and even skills. Advertisers have noticed that consumers often desire commodities that other people want, too. For instance, we can see advertisements that note ‘while supplies last’ or ‘limited time offer’. Research suggests that limited-quantity messages are more persuasive than limited-time messages, though [16]. Scarcity appeals in commercial messages are an efficient strategy to trigger consumers’ value perception of the product (see Ref. [17], for a review). Developed by Brock [18], commodity theory suggests that consumers’ perceived value of a commodity is influenced by its degree of unavailability, especially if they have information that ‘implies that obtaining a resource will be costly in terms of time, effort, and/or money’ [19, p. 5]. In other words, the more limited and resource-intensive the commodity is, the more valuable it is in the eyes of consumers. One psychological explanation of consumers’ desire for rare goods is their need for uniqueness [20]. Owning resources that only a few others possess is an easy way to signal their superior social status. In addition to value perception, cognitive evaluation is also an often-tested outcome variable related to scarcity. For instance, Gierl and Huettl [21] examined the interactive effect of types of scarcity and types of products on persuasion. Their research revealed that when people’s chances of owning a product are reduced due to high demand, they are more likely to have positive product attitudes. Because value perceptions and attitudes can be influenced by messages emphasizing the scarcity of a commodity, it is possible that commodity theory may help explain how messages discussing scarcity help predict intentions to secure a vaccine—a commodity. Cultivation theory While perceived product scarcity is a key variable that may explain vaccine attitudes and behavior in mainland China, another vital factor is information exposure. Examining the role of information exposure, or media use, more broadly as a predictor of vaccination perceptions and intentions leads us to a discussion of cultivation theory. Proposed by Gerbner et al. in 1976, cultivation theory examines the relationship between audiences’ television viewing and evaluation of the world [22]. The core argument of cultivation theory is that compared with light viewers, people who watch television frequently are more likely to internalize the messages and themes from television and believe them to be reflective of the real world [23]. Cultivation analysis initially concentrated on the effects of overall television viewing [22], but has extended to non-television genres, such as online games (e.g. [24]) and social media (e.g. [25]). The present study focuses on Chinese individual’s consumption of online media content regarding the HPV vaccine for several reasons. First, the Internet provides citizens with a high-speed communication environment [26] where they can quickly get the most recent information about new products and technologies, including vaccinations. Thus, it is reasonable to presume that mainland Chinese rely on the Internet to help them understand the HPV vaccine, which is only newly available in this part of the world. Second, HPV vaccination is discussed in this study from a market perspective. We are interested in people’s estimate of demand and supply for the HPV vaccine in mainland China and their attitudes (positive versus negative) toward the vaccine, as these factors can influence behavioral intentions. Social media and the Internet are likely to offer information in which the vaccine is regarded as commodities, thereby shaping scarcity perceptions. For instance, mainland Chinese consumers can make vaccination appointments online and view vaccine product reviews on social media. Under these considerations, therefore, we believe that it would be more appropriate to examine mainland Chinese’s exposure to online content regarding the HPV vaccine than television consumption. In short, people rely on information from the media to understand and think about the world around them. The perception of social reality stored in one’s memory can subsequently affect decision making and behavior. Cultivation theory focuses on the relationship between media exposure and people’s beliefs and worldviews, and as we argue, may help explain why sustained use of online information may help shape mainland Chinese perceptions of how scarce the HPV vaccine is. However, cultivation theory alone does not directly explore the relationship between media exposure and subsequent behaviors. Nabi and Sullivan [27], however, offer guidance for combining cultivation-related concepts with the classical components of Theory of Reasoned Action (developed by Fishbein and Ajzen [28]): attitude, behavioral intention and volitional behavior. Consistent with their hypotheses, Nabi and Sullivan found that heavy television viewers have stronger beliefs about the prevalence of crime and violence in society than light viewers. Those beliefs were positively correlated with opinions that ‘the world is a mean place’, which in turn predicted viewers’ intentions and engagement in protective actions. A direct effect of television viewing on intentions to take protective actions was also found. Based on how cultivation relates to attitudes and behaviors, as well as on the aforementioned literature noting the effects of scarcity perceptions on values and attitudes, we hypothesize that people in mainland China who are heavily exposed to vaccine-related online messages will have a stronger scarcity perception of the HPV vaccine, which in turn will predict their positive vaccine attitudes and intentions. In mainland China, H1: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positively related to vaccination intentions. H2: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positive related to perceived scarcity of the vaccine. H3: Higher levels of perceived scarcity of the HPV vaccine will be positively related to (i) attitudes toward the vaccine, and (ii) vaccination intentions via vaccine attitudes. Influence of presumed influence When examining media effects related to HPV vaccine messages in mainland China, another potential influence of messages discussing the scarce supply of the vaccine is that they may motivate consumers to think about how vaccine messages are also affecting others. That is, we should consider how online information about the HPV vaccine in mainland China influences Internet users’ perceptions that other people may be influenced by these vaccine-related messages. Theoretically, the notion of ‘presumed influence’ can help guide predictions as to the effects of scarcity in this realm. The IPI model, developed by Gunther and Storey [14], is derived from third-person effects (TPEs) research, which argues that people perceive a greater communication influence on others than on themselves [29]. Whereas individuals often do not believe they are directly influenced by media, they tend to believe people are, indeed, influenced by the messages around them. The underlying mechanism of TPEs can be explained by observers’ beliefs that they are different from others, but in a good way. When consuming media messages about negative consequences (e.g. binge drinking), people are confident in their abilities to avoid media influence, but they tend to overestimate others’ susceptibility to them [30, 31]. Unlike the TPEs model, which examines the discrepancy between perceived influence on self and others, the IPI model addresses how people’s perceived communication influence on others directly affects their reactions to the social reality [14]. It consists of four necessary steps: ‘self-exposure—other-exposure—presumed influence on others—own behavior’ [32, p. 471]. Specifically, the more time people spend consuming specific media messages, the more likely they are to believe that other people are also frequently exposed to similar content. This belief of others’ frequent exposure then leads to speculation that others are strongly influenced by that media exposure, which subsequently impacts the individual’s own attitudes and behaviors. According to the IPI model, because people are social in nature, thinking about how others are influenced by media should, in turn, influence our own reactions to media messages. Using the IPI model as a theoretical framework, the indirect effect of media on behavior has been tested in several empirical studies (e.g. [33–35]). In the Chinese context, Jiang and Chia [36] examined the effects of advertising exposure on young adults’ materialism. Their study found that Chinese individuals who frequently watched advertisements were very likely to perceive stronger media influence on their friends, which in turn increased their perceptions that their friends were more materialistic, which then drove up their own materialistic values. A desire to fit in with the perceived social trend likely led them to develop a higher level of materialism. The IPI model is also an important conceptual framework for the present study as it has been applied to scarcity-related messages. Sharma and Roy [37] looked into how scarcity appeals ‘promote a herd mentality and encourage bandwagon behavior’ (p. 83) from the perspective of IPI. They found that respondents’ value perception of a consumer product affected both perceived advertising influence on others and self, respectively. The path between perceived influence on others and purchase intention was mediated by perceived influence on self. That is, it was the participants’ belief that advertising influenced other individuals that, in turn, predicted their own perceived vulnerability toward advertisements and their eventual intention to purchase the product. Based on the IPI model and existing research applying it to the Chinese context and to scarcity-based messages, we offer the following hypotheses: In mainland China, H4: Higher levels of respondents’ self-exposure to online content regarding the HPV vaccine will be positively related to perceived other-exposure to these messages. H5: Higher levels of respondents’ perceived other-exposure to online content regarding the HPV vaccine will be positively related to their perceived influence on others. H6: Higher levels of respondents’ perceived influence on others will be positively related to perceived scarcity of the vaccine. Other considerations In addition to the theoretically derived variables discussed above, it is possible that characteristics of the media users and their backgrounds may elsewise influence responses to the HPV vaccine in mainland China. Below we discuss the potential roles of gender, age, education and income levels in shaping user responses to Internet-based vaccine information in mainland China. Gender differences Although the HPV vaccine has been recommended for both boys and young adult men, the immunization rate for males is lower than for females in the United States [38]. One study by Nan [39] found that in the United States, female undergraduate students are more willing to take the vaccine than are male undergraduates. Additionally, males’ knowledge of the vaccine is relatively limited [40]. One explanation of the gender difference is that ‘public health campaigns have given out the wrong signals that the HPV vaccine is only useful to females’ [41]. Although the data on men versus women HPV vaccine use in China is not yet available, there are some clues from media coverage suggesting that gender differences may exist. Much Chinese newspapers’ coverage of the HPV vaccine stresses the importance of HPV vaccination in preventing women from cervical cancer [42], which is one of the most common cancers diagnosed among Chinese women. However, little media coverage suggests that men should also be vaccinated. Given all these factors, we ask if the women in our sample will have different perceptions of the HPV vaccine than men: RQ1: Will the data fit the model differently for men versus women? Age, education and income Age, educational background and income could also influence many of the perceptions that result in vaccination intentions. In mainland China, different types of HPV vaccines are recommended for different age groups. For instance, Cervarix is recommended for women aged 9–25, while Gardasil 4 is recommended for women aged 20–45 [43]. When it comes to educational background, prior research indicates that the relationship between education level and perceived acceptability of the HPV vaccine is not consistent (see [44], for a review). Jain et al. [45] found that people with an undergraduate degree or more education reported a higher awareness of the vaccine. However, some studies found that lower educational levels are associated with positive attitudes toward the HPV vaccine (e.g. [46]). Income, one dimension of socioeconomic status, may also impact vaccine attitudes and intentions. A positive correlation between parental income and vaccine acceptability was found in prior studies (e.g. [46]). Notably, the HPV vaccine is not free in mainland China and can be quite expensive [47]. It costs more than three hundred US dollars for the three required doses, not mentioning the extra transportation expense if people need to get the vaccine overseas or in Hong Kong. This makes the vaccine difficult to procure for low-income individuals in China [8]. Thus, in addition to the previous hypotheses, we plan to control for age, education and income in the present study. Figure 1 displays the conceptual model that combines the hypotheses and research questions into an overarching model. Fig. 1. Open in new tabDownload slide Conceptual model with hypotheses. Fig. 1. Open in new tabDownload slide Conceptual model with hypotheses. Materials and methods Participants We recruited mainland Chinese adults aged 18–45 to participate in this study. Although the HPV vaccine in China is accessible to people aged 9–45, our study did not recruit adolescents because their perceptions of health issues can be significantly influenced by their parents [48]. Furthermore, given the high cost of the vaccine in China, adolescents are less likely to get the vaccine without parental support and financing. Four hundred and twenty-four respondents were recruited from Wen Juan Xing (a Chinese data collection website) using a sample service. Each respondent was thanked and gained one US dollar compensation after completing the survey. Since one of our outcome variables is vaccination intentions, those who have already received an HPV vaccine (n = 65) were excluded, leaving a final sample size of 359. The average age of the respondents was 24.69 years old (SD = 3.55). The ages of respondents ranged from 18 to 33. About two-thirds (n = 240) of the respondents are women and 119 (33.10%) are men. Regarding educational background, 300 (83.60%) respondents’ highest education level to date is the bachelor’s degree; 28 (7.80%) of them are graduate students; 28 (7.8%) of them gained a high school diploma or equivalent; 3 (0.80%) respondents’ highest education degree is a middle school diploma. In terms of income, 48 (13.40%) respondents’ monthly household income was more than 15 000 CNY (Chinese yuan); 65 (18.10%) reported income of 12 000–15 000 CNY; 80 (22.30%) reported income of 9000–12 000 CNY per month; 65 (18.10%) reported income of 6000–9000 CNY per month; 81 (22.60%) reported income of 3000–6000 CNY per month; and 20 (5.60%) reported earning less than 3000 CNY monthly. Notably, the Chinese urban household’s income per capita for 2018 was 39 250.8 CNY [49]. Measures In the questionnaire, we measured self-exposure to online content related to the HPV vaccine, perceived other-exposure, perceived influence on others, perceived scarcity, vaccine attitudes, vaccination intentions and demographic information. Given that our respondents are Chinese citizens who may not understand English, a native mandarin speaker translated the questionnaire into Simple Chinese prior to distribution. All means and standard deviations are reported in Table I. Table I. Partialcorrelation between model variables Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Note: All partial correlations control for gender, age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Table I. Partialcorrelation between model variables Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Variable . M . SD . 1 . 2 . 3 . 4 . 5 . 1. Self-exposure 2.45 0.82 __ 2. Perceived other-exposure 4.91 1.10 0.45*** __ 3. Perceived influence on others 5.40 1.11 0.26*** 0.49*** __ 4. Perceived scarcity 4.74 1.15 0.35*** 0.35*** 0.25*** __ 5. Vaccine attitude 5.81 1.32 0.11* 0.18*** 0.18*** 0.16** __ 6. Vaccination intention 3.43 1.20 0.28*** 0.14** 0.16** 0.26*** 0.28*** Note: All partial correlations control for gender, age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Based on Gunther et al. [34], we used four items to measure media self-exposure, i.e. ‘In the recent period, how often have you seen HPV vaccine-related news on the internet’, “how often have you seen HPV vaccine-related content in social media, such as Weibo, WeChat, Red Book’, “how often have you seen HPV vaccine-related online discussions’ and ‘how often have you searched for HPV vaccine-related information on the internet’. The answer options were never (1), rare, sometimes, often or always (5). All items comprised a composite index for the variable of self-exposure. To get the average score, we cumulated the points received from each item and divided them by the total amount of items. The scale demonstrated good internal consistency (Cronbach’s α = 0.85). The perception of other-exposure was also treated as a composite variable and measured by four items, i.e. ‘how likely do you think that others have been reviewing HPV vaccine-related news on the internet’, ‘others have been reviewing HPV vaccine-related content in social media, such as Weibo, WeChat, Red Book’, ‘others have been reviewing HPV vaccine-related online discussions’. The answer options for these items ranged from very unlikely (1) to very likely (7). We also asked respondents to respond to an item drawn from Jiang and Chia [36] ‘to which degree do you think that others have been paying attention to online content related to the HPV vaccine’ with answer options ranged from never paid attention (1) to paying lots of attention (7). The scale demonstrated good internal consistency (Cronbach’s α = 0.88). To measure perceived influence on others, one seven-point scale item was employed, i.e. ‘to which degree do you think these online messages have influenced the opinions of other viewers toward the vaccine’ [50]. To assess perceived scarcity of the HPV vaccine in mainland China, respondents were asked ‘to which extent do you agree that the HPV vaccine is rare in mainland China’, ‘to which extent do you agree that the HPV vaccine demand exceeds its supply in the domestic market’ and ‘to which extent do you agree that due to short supply many people tried to get the vaccine outside the country’ using seven-point answer options from strongly disagree to strongly agree. The internal consistency of the scale is good (Cronbach’s α = 0.84). Attitude toward the HPV vaccine [51] was measured using a seven-point semantic differential single-item scale. That is, respondents were asked, ‘I think the HPV vaccine is bad/good’. Vaccination intention [52] was also measured using one single item, i.e. ‘In the near future, how likely would you take the vaccine’ with answer options ranged from very unlikely (1) to very likely (5). We developed a set of items to ascertain demographic information about respondents’ gender, age, education background and monthly family income. Specifically, we asked respondents about gender, i.e. male/female, age (open-ended question), and their highest degree of education they have received so far (the answer options contain middle school diploma, high school diploma, bachelor’s degree, master’s degree, doctoral degree and post-doctoral degree). Regarding income, respondents were asked ‘how much is your household income per month’ with answer options ranged from less than 3000 to 15 000 CNY or more. Table I shows the partial correlation between model variables after controlling for demographic variables, i.e. gender, age, education and income that might affect vaccine attitudes and intentions. Results To address the hypotheses, we performed a path analysis using SPSS Amos 25. After controlling for gender, age, education level and monthly income (i.e. we allowed each of these control variables to predict each of the variables in the conceptual model), the model demonstrated acceptable fit: χ2 = 23.26, df = 7, P < 0.01; CFI = 0.972; RMSEA = 0.081 (PCLOSE = 0.071; 90% confidence interval = 0.046 to 0.118); SRMR = 0.032. Given that the chi-square goodness-of-fit test is sensitive to sample size, we are not surprised that the P-values was significant given that larger samples (e.g. over 200 respondents) frequently result in a χ2 at P < 0.05 [53]. The standardized path coefficients and their significance values were used to test the hypotheses. Specifically, respondents’ self-exposure to online content regarding the HPV vaccine is directly related to their intentions to be vaccinated (β = 0.20, P < 0.001). H1 was supported. With regard to cultivation effects, higher levels of self-exposure to online content regarding the HPV vaccine is a positive predator of perceived scarcity of the vaccine in mainland China (β = 0.31, P < 0.001). Hypothesis 2 was supported. The scarcity perception, in turn, is positively related to respondents’ attitudes toward the vaccine (β = 0.17, P < 0.01). In other words, people who perceived the HPV vaccine as scarce and rare in mainland China tend to have positive vaccine attitudes. H3a was supported. In addition, perceived scarcity of the HPV vaccine in China is positively related to vaccine attitude, which in turn enhance intentions to be vaccinated (β = 0.17 * 0.22 = 0.04). The indirect effect is significant in the model vis 2000 bootstrap samples (P < 0.01). Regarding the IPI, higher levels of respondents’ self-exposure to online content regarding the HPV vaccine is positively related to perceived other-exposure to these messages (β = 0.45, P < 0.001). H4 was supported. The perception of other-exposure significantly increase respondents’ perceived media influence on others (β = 0.52, P < 0.001), which in turn increase their perceived scarcity of the vaccine (β = 0.17, P < 0.001). H5 and H6 were supported. To sum up, all of the hypothetical paths in the model are significant and in the expected direction (see Fig. 2). Fig. 2. Open in new tabDownload slide Path analysis results after controlling for gender, age, education and income. Parameters are standardized coefficients. *P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001. Fig. 2. Open in new tabDownload slide Path analysis results after controlling for gender, age, education and income. Parameters are standardized coefficients. *P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001. RQ1 asked whether the data fit the model differently for men versus women. To answer this question, we performed a multiple group path analysis to examine how the path for the female group differs from the path for the male group. First, we ran an unconstrained model that allowed all estimates for males and females to differ. After controlling for age, education and monthly income, the overall fit of the unconstrained model was good: χ2 = 29.91, df =14, P < 0.01; CFI = 0.968; RMSEA = 0.056 (PCLOSE = 0.319; 90% confidence interval = 0.028 to 0.084); SRMR = 0.035. As expected, the model fits better for women. All of the paths for the female group are significant, while some paths for the male group are nonsignificant (see Table II). Next, we ran a constrained model with all of the regression weights set to be equal for men and women. Compared with the unconstrained model, the constrained model resulted in a nonsignificant increase in test difference, Δχ2 = 31.898, df = 23, P = 0.102. This means that, overall, the model did not fit the data differently for women versus men. However, the possibility remained that there could be differences on the path level. As such, we reviewed the critical ratios for the unconstrained model (where paths were allowed to differ between men and women). These values revealed that the path linking vaccine attitude and intention was different between men and women. Hence, we ran another model that solely constrained this path and compared the difference between it and the unconstrained model. This test demonstrated that constraining this particular path results in a significantly worse fit, Δχ2 = 4.250, df = 1, P = 0.039. That is, the path vaccine attitude → vaccination intention is significantly different for women than men. Table II. Unstandardized path coefficient estimates and their significance tests . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* Note: Control for age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Table II. Unstandardized path coefficient estimates and their significance tests . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* . Coefficient . SE . CR . Paths for the female group (N = 240)  Self-exposure → vaccination intention 0.33 0.07 4.73***  Self-exposure → perceived scarcity 0.48 0.08 6.08***  Perceived scarcity → vaccination intention 0.16 0.05 3.01**  Perceived scarcity → vaccine attitude 0.25 0.07 3.40***  Vaccine attitude → vaccination intention 0.27 0.04 6.35***  Self-exposure → perceived other-exposure 0.56 0.07 7.65***  Perceived other-exposure → perceived influence on others 0.47 0.06 8.00***  Perceived influence on others → perceived scarcity 0.16 0.06 2.50* Paths for the male group (N = 119)  Self-exposure → vaccination intention 0.13 0.17 0.79  Self-exposure → perceived scarcity 0.31 0.14 2.20*  Perceived scarcity → vaccination intention 0.11 0.11 1.03  Perceived scarcity → vaccine attitude 0.08 0.12 0.67  Vaccine attitude → vaccination intention 0.08 0.08 0.93  Self-exposure → perceived other-exposure 0.74 0.12 6.06***  Perceived other-exposure → perceived influence on others 0.61 0.08 7.18***  Perceived influence on others → perceived scarcity 0.20 0.08 2.35* Note: Control for age, education and income. * P ≤ 0.05; ** P ≤ 0.01; *** P ≤ 0.001. Open in new tab Discussion The results presented above largely supported our hypotheses and give credence to incorporating an interdisciplinary perspective to understand why individuals in a country with a scarce supply of the HPV vaccine seek it out. To start, the data revealed that higher levels of respondents’ self-exposure are positively related to intent to be vaccinated. People who are frequently exposed to online content regarding the HPV vaccine are more willing to take the vaccine in comparison with light viewers. One potential explanation, which has been supported by Li et al.’s [42] content analysis, is that Chinese newspapers generally frame the vaccine in a favorable tone. Additionally, the results revealed the influence of online message viewing on vaccine intentions via scarcity perceptions and vaccine attitudes, which supports the cultivation effect on the attitude–intention relationship. Specifically, we found that viewing online media is positively related to respondents’ perceived scarcity of the HPV vaccine. The finding resonates with the cultivation theory by Gerbner and Gross [13] in which people who heavily watch television tend to believe what the medium tell them. There is a significant proportion of online news and consumer-generated content noting the HPV vaccine shortage on the mainland. As a result, people who are heavily exposed to these messages are very likely to regard the vaccine as a valuable commodity as not everyone is capable of owning it. From a marketing perspective, this finding suggests that using scarcity appeals may be an effective communication strategy for promoting the HPV vaccine in mainland China. Moreover, scarcity perceptions mediated the relationship between self-exposure and attitude toward the vaccine. In other words, people who are frequently exposed to vaccine messages are likely to believe that the vaccine is in short supply and thereby develop positive attitudes toward it. Given that a commodity’s unavailability can enhance value perceptions [18], it makes sense that scarcity perceptions and vaccine attitudes are positively correlated. On the other hand, however, the finding implies that when people spend most of their attention on how to get a vaccine that focus may reduce critical analyses of the vaccine effectiveness. As expected, and in line with the IPI model [14], our study revealed an indirect effect of online information consumption on scarcity perceptions via perceived influence of media on others. People who heavily view online content regarding the HPV vaccine tend to develop a stronger scarcity perception, as they believe that others also consume a lot of such content and develop a higher susceptibility to persuasion. This finding is consistent with Davison [29], who wrote that ‘there are always some people who will rush to the stores the moment when they hear reports of any possible shortage’. The reason is that they perceive a great impact of these messages on others and ‘want to stock up before the hoarders remove all goods from the shelves’ (p. 13). Given the fact that China has a large population that places a burden on resources, everyone’s basic needs cannot always be met, including vaccination. When Chinese people perceive that others are very vulnerable to vaccination messages, our data suggest that they tend to envision that others must work hard to purchase it, which may make the vaccine shortage worse. Perceived scarcity may generate a sense of insecurity and anxiety, causing people to desire the vaccine even more. Future research could investigate whether or not insecurity and anxiety result when Chinese people perceive the scarcity of the HPV vaccine to be high, and how these feelings influence vaccination intentions. In addition, this finding could reflect health disparity across nations. The higher level of self-exposure to online content regarding the vaccine has a positive correlation with scarcity perception via presumed influence on others. However, this would be unlikely to happen in developed countries where people can get the subsidized HPV vaccine at many locations. Unlike mainland Chinese individuals, who are worried about the vaccine’s unavailability, people in developed countries appear to have more safety concerns about the vaccine. It is worth noting that, according to Chen [54], the biggest HPV vaccine consumers in mainland China are ‘young, urban, middle-class women’, which is quite different from developed countries that market to young adolescents between the ages of 9 and 14 years old [3]. These cross-cultural differences point to the importance of conducting additional research in this area that directly compares media effects across countries. This study also examined important gender differences. The multiple group analysis results showed that the model fits better for women than for men. For the female group, all of the hypothetical paths are significant and in the expected direction. Yet for the male group, paths involved with vaccine attitudes or intentions are no longer significant. In other words, women who have positive attitudes toward the HPV vaccine tend to have higher intentions to be vaccinated. For the male group, however, positive vaccine attitude does not necessarily predict intentions. The finding is consistent with Nan [39], which also found willingness to get the HPV vaccine is relatively low among male college students. Also, we can see that the relationship between self-exposure and scarcity perceptions is more evident for Chinese women than men. As such, scarcity appeals may be better targeted toward female audiences. Chinese men might perceive these vaccine-related content differently. Future research could use additional variables, perhaps including social norm perceptions related to other men’s acceptance of vaccination, to better predict men’s reactions to online vaccine information. While the aforementioned results make many contributions to the literature, there are also several limitations to the study that must be mentioned. First, the convenience sample included twice as many women as men. Additional research should try to recruit more men. Second, some variables (i.e. presumed influence on others, vaccine attitude and intention) were measured using a single item, and future research with a longer questionnaire could help improve the internal validity of these items. Third, given the positive correlation between online media use and vaccination intentions, we speculate based on anecdotes that the vaccine-related content on the Internet in China is mostly framed in a positive and benefiting tone, but that is not known for sure. Additional content analyses of vaccine-related online information in mainland China, especially work that can compare and contrast information from news, government, and user-generated sources, are needed to help assess how the nature of online content may more specifically influence vaccine perceptions and intentions. Conclusion In conclusion, the present study integrated a market-based approach with previously applied conceptual models to better understand how online media use can shape HPV vaccination perceptions and intentions in mainland China. The findings point to the importance of understanding the commodity status and scarcity perceptions of a health-related product as part of the larger issue of understanding the interplay between media use and health behaviors. Future work can build of the findings presented here to help develop campaigns and health interventions aimed at educating and facilitating HPV vaccination in mainland China and in other countries where the vaccine is scarce. Conflict of interest statement The authors have no conflict of interests to declare. This article was presented at 2019 AEJMC, Toronto. References 1 Castellsagué X. Natural history and epidemiology of HPV infection and cervical cancer . Gynecol Oncol 2008 ; 110 : S4 – 7 . 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Journal

Health Education ResearchOxford University Press

Published: Aug 13, 18

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