Testing the Cultural Cognition Hypothesis in a Canadian Undergraduate Student Population Ioana-Smarandita Arbone A thesis submitted to the Faculty of Graduate and Postdoctoral Studies in partial fulfillment for the Master of Science in Health Systems Telfer School of Management University of Ottawa September 2014 Thesis supervisor: Dr. Kevin Brand, Telfer School of Management, University of Ottawa. Thesis co-supervisor: Dr. Wojtek Michalowski, Telfer School of Management, University of Ottawa. © Ioana-Smarandita Arbone, Ottawa, Canada, 2014 Acknowledgments I would like to thank the many people that made this project possible. First and foremost, I want to express my gratitude to my supervisors, Dr. Kevin Brand and Dr. Wojtek Michalowski, who provided invaluable support, encouragement, feedback, and guidance at all stages of my thesis writing. I also want to thank the Telfer School of Management for giving me the opportunity to conduct research at this Faculty. Finally, I want to thank my family and friends for their support and encouragement during my graduate studies. ii Abstract Background and Research Goals. This study aims to see the association between worldviews and HPV vaccine risk perceptions in a sample of Canadian undergraduate students enrolled in Health Sciences and Business programs at the University of Ottawa. It is a follow-up to the Kahan et al. (2010) research in the U.S. that showed the association to be present in a nationally representative U.S. sample. In addition to searching for this association in the Canadian context, this study examines whether worldviews differ between (a) men and women; and (b) students with health sciences and with business degrees. Furthermore, this study tests a set of candidate questions for supplementing the worldview questionnaire of Kahan et al. (2010). Design and Analysis. The data for the study was collected using an Internet-based questionnaire and the study was conducted in two phases. During the first phase, a customized worldview questionnaire was administered. During the second phase, questions related to HPV and Canadian healthcare system were presented. In order to analyze the data, regression models, correlation matrices, and MANOVAs were employed. Results. The findings of this study are that worldviews are related to HPV vaccine risk perceptions. However, though hierarchism was a better predictor then individualism in the Kahan et al. (2010) study, our present research indicates that individualism is a better predictor. Also, our findings, contrary to those of Kahan et al. (2010), suggest that the more individualistic a person is, the more likely he or she is to perceive the vaccine as being safe. With respect to gender, men were more hierarchical. Also, when females in health sciences were compared to women in business, the latter were also more hierarchical. Finally, three healthcare items were identified as possibly benefiting from refinement and inclusion in a worldview instrument more suited for the Canadian context. iii Table of Contents Acknowledgments .................................................................................................................... ii Abstract ................................................................................................................................... iii Table of Contents ...................................................................................................................... 1 Table of Tables .......................................................................................................................... 4 Table of Figures ........................................................................................................................ 7 Chapter 1: Introduction ............................................................................................................. 8 1.1 Background ...................................................................................................................... 8 1.2 Research Objectives and Hypotheses .............................................................................. 9 1.3 Thesis Plan ..................................................................................................................... 10 Chapter 2: Literature Review .................................................................................................. 11 2.1 What is HPV? ................................................................................................................ 12 2.2 HPV Vaccine ................................................................................................................. 15 2.3 Policies Governing HPV Vaccination ........................................................................... 16 2.4 Arguments For and Against Vaccination ...................................................................... 18 2.5 Cultural Theory ............................................................................................................. 20 2.5.1 Literature on Risk Perception ................................................................................. 21 2.5.2 Evolution of Cultural Theory .................................................................................. 25 2.5.3 Limitations/Considerations of Cultural Theory ...................................................... 27 2.5.4 Applications of Cultural Theory ............................................................................. 28 2.6 Cultural Theory and Cognition ...................................................................................... 29 2.7 Cultural Cognition and the HPV Vaccination Debate in the United States and Canada ............................................................................................................................................. 32 1 Chapter 3: Methodology ......................................................................................................... 34 3.1 Participants .................................................................................................................... 34 3.2 Materials ........................................................................................................................ 34 3.3 Procedure ....................................................................................................................... 39 3.4 Design and Statistical Methods for Each Hypothesis .................................................... 39 Chapter 4: Results ................................................................................................................... 42 4.1. Cultural worldviews and perceptions of the HPV vaccine are related. ........................ 44 4.2. Gender and degree are related to worldviews .............................................................. 54 4.3. Cultural worldviews and views of the roles that the healthcare system plays are related. ................................................................................................................................. 60 Chapter 5: Discussion ............................................................................................................. 64 5.1 Limitations ..................................................................................................................... 68 5.1.1 Limitations Related to Data .................................................................................... 68 5.1.2 Limitations Related to Methodology ...................................................................... 68 5.1.3 Limitations Related to the Cultural Cognition Theory ........................................... 69 5.2 Other Considerations: The Effect of Media on Risk Perceptions ................................. 70 5.3 Future Research and Implications of This Study .......................................................... 71 References ............................................................................................................................... 73 Appendix 1 Questionnaire Used in this Study ........................................................................ 82 Questionnaire Part 1 ............................................................................................................ 82 Questionnaire Part 2 ............................................................................................................ 88 Appendix 2 Reliability Analyses ............................................................................................ 92 Hierarchism Scale ................................................................................................................ 92 Individualism Scale ............................................................................................................. 94 HPV Vaccine Risk Perceptions Scale ............................................................................... 100 2 Healthcare Questions Scale ............................................................................................... 106 Appendix 3 Description of Continuous Variables ................................................................ 112 Appendix 4 Description of Categorical Variables ................................................................ 113 Appendix 5 Assumptions and Explanations for Multiple Regression .................................. 123 3 Table of Tables Table 1. Average Annual Number of Cases and Age-Standardized Incidence of HPV- Associated Cancers Among Persons Aged 15 Years