Open Access Research Print and online newspaper coverage of the link between HPV and oral cancer in the UK: a mixed-methods study Rachael H Dodd, Laura A V Marlow, Alice S Forster, Jo Waller To cite: Dodd RH, ABSTRACT Strengths and limitations of this study Marlow LAV, Forster AS, et al. Objectives: The role of human papillomavirus (HPV) Print and online newspaper in some oral cancers has been reported in the news ▪ coverage of the link between This is the first study to examine the content of press, though little is known about the content of these HPV and oral cancer in the newspaper articles addressing the relationship UK: a mixed-methods study. articles. This study aimed to examine how frequently between human papillomavirus (HPV) and some BMJ Open 2016;6:e008740. the link between HPV and oral cancer has been oral cancers. doi:10.1136/bmjopen-2015- reported in the news press and to examine the content ▪ Using NexisUK to examine UK media coverage of 008740 of these articles. the link between HPV and oral cancer provides a Design: UK media articles were searched for articles systematic analysis of a large number of ▸ Prepublication history for relating to oral cancer and HPV in the database publications. this paper is available online. NexisUK. Of 854 articles identified by the initial search, ▪ This study is limited to UK publications and to To view these files please 112 were eligible for inclusion (2002–2014) and print and online media, so the results may not visit the journal online content analysis was used to determine the main be representative of wider information available (http://dx.doi.org/10.1136/ themes discussed. to the public. bmjopen-2015-008740). Results: Themes included actor Michael Douglas’ ▪ The articles in the study were only examined for claim that his throat cancer was caused by HPV, the content and not for accuracy of the information Received 11 May 2015 Revised 17 December 2015 riskiness of oral sex, health information (including HPV presented. Accepted 9 February 2016 as a cause of oral cancer) and the need to vaccinate boys against HPV. Many articles also referred to the link between HPV and cervical cancer and the transmission of HPV are thought to be a increasing incidence of HPV-related oral cancer. The greater number of sexual and (for oral infec- – largest peak in articles occurred when Michael Douglas tion) oral sex partners7 10 due to greater discussed his cancer (June 2013). Facts about HPV exposure to the virus. and references to research were provided in some Prior to the introduction of the HPV vac- articles. cination in 2008, public awareness of HPV Conclusions: The link between HPV and oral cancer (primarily in the context of cervical cancer) and the transmission of HPV via oral sex was regularly was measured in population-based studies to discussed, yet coverage often lacked detailed health be between 25% and 50%.11 12 The HPV vac- information. This could increase awareness of the link 13 between oral sex and HPV risk, but may also lead to cination attracted a lot of media attention public concern about oral sex as a sexual behaviour. and knowledge of HPV appears to have increased following its introduction.14 In an online survey across the UK, USA and Australia following the introduction of the HPV vaccine, 39% of men and 62% of women INTRODUCTION in the UK reported having heard of HPV.15 Traditional risk factors for oral cancer are In the oral cancer context, no UK studies tobacco and alcohol, but there is now over- have yet examined knowledge that HPV is a whelming evidence that human papilloma- risk factor for oral cancer. In the USA, virus (HPV) plays a causal role in some types dental hygienists in North Carolina were 1–4 Department of Epidemiology of the disease. At least 25% of the esti- found to have low knowledge of HPV as a & Public Health, Cancer mated 85 000 oropharyngeal cancers diag- risk factor for oral cancer compared with 16 Research UK Health nosed worldwide in 2008 were HPV-positive.5 tobacco and alcohol. In a USA population- Behaviour Research Centre, HPV is a common sexually transmitted infec- based online survey, HPV was recognised as UCL, London, UK tion, with high-risk types shown to be respon- a common risk factor for mouth and throat Correspondence to sible for up to 5% of all cancers worldwide, cancer by fewer than 1% of participants, Rachael H Dodd; particularly cervical and other anogenital and even when prompted explicitly about [email protected] cancers.6 The main risk factors for the link, just 13% said they had heard of Dodd RH, et al. BMJ Open 2016;6:e008740. doi:10.1136/bmjopen-2015-008740 1 Open Access the association.17 In an internet survey of men, a reported and how the link between HPV and oral greater proportion linked HPV with genital warts than cancer has been presented. with oral cancer, with 43% identifying infection with HPV as a potential cause of oral cancer.18 Public aware- ness of the signs and risk factors for head and neck METHODS – cancer has also been shown to be poor19 21 and the The NexisUK database was used to search for print and majority of oral cancers are diagnosed at an advanced online articles in the UK relating to HPV and oral stage.22 cancer. NexisUK is an online database providing full-text As the media has been shown to influence people’s access to international, national and regional news beliefs23 and is considered a major source of health sources, and is updated daily. The search was conducted information for many,24 it is possible that media cover- on the 20 August 2014 with no date limits applied. The age of the link between HPV and oral cancer may influ- search terms ‘oral cancer’, ‘mouth cancer’, ‘throat ence public awareness and perceptions. The British cancer’, ‘oropharyngeal cancer’, ‘head and neck cancer’ media is no stranger to reporting stories about people in were entered into the database separately, limited to the public eye with cancer, most notably the stories of major mentions (in the headline, lead paragraph or Jade Goody (an English reality television personality), indexing) and combined with (HPV OR human papillo- Kylie Minogue (an Australian singer/songwriter) and mavirus) within UK publications. Newswire and non- Angelina Jolie (an American actress). Metcalfe et al25 business news publications (eg, obituaries, sports) were reported that an increased public interest in disease pre- not searched. The full text of each publication was vention can follow a celebrity diagnosis. In the UK, the reviewed by RHD. Newspaper articles were categorised case of Jade Goody (who died of cervical cancer) was using Newsworks30 as ‘broadsheet’ newspapers (more associated with an increase in the number of women intellectual in content eg, The Guardian, The Times), attending cervical screening.26 In 2013, American actor ‘middle market’ newspapers (coverage of entertainment Michael Douglas disclosed in an interview with The and important news stories eg, Sunday Express, London Guardian newspaper that his throat cancer was ‘caused Evening Standard) and ‘tabloid newspapers’ (reporting by HPV which actually comes about from cunnilingus’. mostly on sensational material, eg, The Sun, This disclosure received global attention, giving the Kidderminster Shuttle). Regional newspapers were cate- media an opportunity to discuss the link between HPV gorised by discussion. and oral cancer. However, media reports are sometimes criticised for the lack of detail they provide, for example, Quantitative analysis—frequency of articles with the announcement of Angelina Jolie’s double mast- The frequency of reporting of the link between HPV ectomy many failed to give information about the rarity and oral cancer was analysed using a frequency count. of her condition.27 The number of articles per month reporting the link Media priming may be used to strengthen the associ- was plotted from the first publication to the most recent ation between a person’s existing beliefs and their sub- publication. sequent behaviour by making these beliefs more accessible.28 Mass media campaigns for cancers such as breast and lung (eg, the Cancer Research UK Be Clear Qualitative analysis—content of the articles on Cancer campaign) have been shown to be effective The headlines of all articles were analysed descriptively. in increasing awareness of key symptoms for these The content of eligible articles was analysed using cancers and increases in general practitioner attend- Framework Analysis.31 RHD first familiarised herself with ance.29 As this shows, media coverage is one route the content by reading through all the eligible articles, through which public understanding of health issues making notes of recurring themes and summarising might be improved, but little is known about British each article. Using the qualitative package NVivo V.10, a media coverage of the link between HPV and oral list of codes was generated from the data and these cancer. The media has been shown to be a common codes were applied to the data. The data were sum- source of information about HPV12 and greatly influ- marised and organised into a matrix of main themes ences public opinion, and as such it is crucial to and subthemes, with each row representing an article examine how the link is portrayed by the British media. and each column representing a theme/subtheme. ASF As the media may play an important role in fulfilling coded 20% of the articles to test inter-rater reliability. the information needs of the public, examining the Second coding of 20% of the articles has been consid- content of articles will establish what information is ered sufficient in similar studies.32 33 Cohen’s κ across being conveyed and how this is communicated.