National Infertility Awareness Week and internet search volume: a Google Trends analysis

Using Google Trends, we evaluated National Infertility Awareness Week through the lens of internet search volumes.  During the campaign, internet search volume for the term “infertility” increased, but only to a modest degree.

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Authors: 

Mehul S. Patel (MD)a, Joshua A. Halpern (MD MS)a, Anne L. Darves-Bornoz (MD)a, Channa Amarasekera (MD), Mary Kate Keeter (MPH)a, Nelson E. Bennett (MD)a, and Robert E. Brannigan (MD)a

a Department of Urology, Northwestern University Feinberg School of Medicine

Abstract:

Objective: To investigate National Infertility Awareness Week (NIAW) using internet search volumes as a proxy for success with Breast Cancer Awareness Month (BCAM) and Testicular Cancer Awareness Month (TCAM) as gender specific comparisons.

Design: Retrospective, cross-sectional study examining internet search trends using Google Trends.

Setting: Not applicable.

Patient(s): Google Search users from 2010 to 2018 who queried the terms “infertility”, “breast cancer”, and “testicular cancer”.

Intervention(s): None. 

Main Outcome Measure(s): Substantial rise in relative search volume (RSV), defined as a two-fold rise for each term during their respective awareness campaigns compared to baseline.

Result(s): Search volumes for “infertility” increased from a mean RSV of 77.5 at baseline to 98.0 during NIAW, a mean yearly increase of 27.1% during the study period, not meeting our definition of substantial rise. Search volumes for “testicular cancer” increased from a mean RSV of 70.9 at baseline to 86.2 during TCAM, a mean yearly increase of 22.7%, also not substantial. In contrast, BCAM led to a substantial increase in mean RSV for “breast cancer” from 28.1 at baseline to 100 during the awareness month with a mean increase of 263.1%. 

Conclusion(s): Search volumes for “infertility” modestly increased during NIAW. However, the rise in search volume was notably much less than the associated rise in “breast cancer” searches during BCAM. Further studies are needed to explore methodologies that might help further increase the impact of this important campaign.

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Introduction

Health awareness campaigns attempt to improve public health by disseminating knowledge of the impact of various diseases, prevention, and treatment options. Founded in 1989, National Infertility Awareness Week (NIAW) is one such campaign that was established to increase public knowledge regarding infertility. As one of the largest public awareness campaigns addressing this important issue, NIAW aims to “remove the stigmas and barriers that stand in the way of building families” and help those with infertility learn about treatment options.

An estimated 1 in 8 couples in the US suffers from infertility (1), yet multiple studies have demonstrated that overall knowledge of infertility is often lacking (2). In today’s digital age, the internet has become an essential resource for those seeking health-related information. Specifically for infertility, online educational materials have been shown to improve knowledge, highlighting the integral role the internet plays in fertility education (3). 

Despite a long history for many awareness campaigns, few programs have demonstrated effectiveness mainly due to limited metrics. As the internet is now an established resource, search engine traffic has emerged as one possible indicator of success. Through the lens of internet search volume, studies have evaluated the success of various health campaigns with Google Trends (Google, Mountain View, California), an innovative platform that allows for evaluation of search query volume over time (4-6).

NIAW remains one of the longest running infertility awareness campaigns, yet its efficacy in generating interest has not been evaluated. In contrast, Breast Cancer Awareness Month (BCAM) is one of the most efficacious, well-known campaigns (7). Using Google search volume as a proxy for success, we attempt to evaluate NIAW using BCAM as a successful awareness campaign comparison. Given that breast cancer is gender specific and infertility affects all comers, we also evaluated Testicular Cancer Awareness Month (TCAM) for a male-specific comparison.

Materials and Methods

Google Trends was developed to evaluate search engine traffic on Google Search, providing users with a means of examining search queries over time and geographic location. As a limitation of the platform, the absolute number of searches for a particular query is not available. Instead, Google Trends reports data using relative search volume (RSV), a metric without units that runs from 0 – 100.  During a designated timeframe, the point of highest search activity will be defined as 100 with all other time points scaled accordingly, allowing users to investigate trends in search volume and the impact of public events.

Using approaches similar to those in prior studies (4), we chose the search terms “infertility”, “breast cancer”, and “testicular cancer” as the representative searches for each awareness campaign. Other related search terms were evaluated but demonstrated low search volumes in comparison, and therefore, these simple terms were chosen to capture the broadest searches. Gender-specific search terms were initially investigated (i.e. “male infertility” and “female infertility”) but returned with very low search volume in comparison to “infertility” and were, therefore, abandoned. We also performed additional searches using the terms “fertility” and “IVF” (in vitro fertilization).

To represent the most current trends, we examined volumes from 2010-2018, evaluating each year during the study period separately. Baseline annual RSV was calculated for each search term by determining the mean weekly RSV for each year.  The RSV was then determined for NIAW, BCAM, and TCAM.  Awareness campaign RSV was then compared with the yearly baseline RSV. As a simple, reproducible primary outcome, we chose to define substantial rise in RSV as a 100% increase from baseline.  Statistical analysis was performed using Microsoft Excel® (Microsoft, Redmond, WA).

Results

Figures 1-3 show yearly search volume trends for the queries “infertility”, “breast cancer”, and “testicular cancer” from 2010 to 2018.  While search volume for “infertility” and “testicular cancer” seems fairly stable with no discernable pattern throughout the year, search volume for “breast cancer” demonstrates a clear peak each year during October in relation to BCAM. Both NIAW and TCAM show no such pattern during their respective awareness campaigns each year. In order to evaluate the possibility of searches for infertility through other terms, we also evaluated the terms “fertility” and “IVF” (Supplemental Figure 1). Similar to “infertility”, both “fertility” and “IVF” fail to demonstrate strong cyclic peaks corresponding to NIAW.

Figure 1: Monthly relative search volume (RSV) from 2010 – 2018 for the search terms “Infertility”.

Figure 2: Monthly relative search volume (RSV) from 2010 – 2018 for the search term “Breast Cancer”.

Figure 3: Monthly relative search volume (RSV) from 2010 – 2018 for the search term “Testicular Cancer.”

Supplemental Figure 1: Relative search volume (RSV) from 2010 – 2018 for the search terms “Infertility”, “Fertility”, and “IVF” (In-Vitro Fertilization). 

Table 1 demonstrates percent increase of RSV relative to baseline. Search volumes for “infertility” increased from a mean RSV of 77.5 at baseline to 98.0 during NIAW with a mean yearly search volume increase of 27.1% during the study period, not meeting this study’s definition of substantial rise. Search volumes for “testicular cancer” increased from a mean RSV of 70.9 at baseline to 86.2 during TCAM, a mean yearly increase of 22.7%, also not meeting this study’s definition of substantial rise. In contrast, BCAM led to a substantial increase in mean RSV for “breast cancer” from 28.1 at baseline to 100 during the awareness month with a mean increase of 263.1%. While a lower baseline RSV for “breast cancer” compared to “infertility” and “testicular cancer” may seem counterintuitive at first, it is important to evaluate this is in the context of Google Trends methodology. In our study, the highest search volume for a specific search term during a given year is set to the maximum RSV of 100 with all other time points during the year scaled accordingly. Therefore, a large difference in peak search volume compared to baseline will drive down baseline RSV.

 

 

National Infertility Awareness Week (% Increase in RSV)

Breast Cancer Awareness Month (% Increase in RSV)

Testicular Cancer Awareness Month (% Increase in RSV)

2010

23.5

284.6*

58.7

2011

1.8

257.1*

14.2

2012

37.0

334.8*

25.5

2013

12.8

308.2*

10.3

2014

19.0

316.7*

11.1

2015

37.9

257.1*

47.1

2016

34.2

194.1*

17.0

2017

44.9

203.0*

7.6

2018

32.5

212.5*

12.3


Table 1: Percent rise in relative search volume (RSV) for the terms “breast cancer,” “testicular cancer,” and “infertility” during Breast Cancer Awareness Month, Testicular Cancer Awareness Month, and National Infertility Awareness Week from 2010 – 2018. *Denotes substantial rise in RSV as we have defined for this study (>100% increase in RSV).

Discussion

This study represents the first attempt to evaluate the change in internet search volume associated with  NIAW. In comparison to the large increase in search volume seen for “breast cancer” during BCAM, there was a very modest increase in search volume for “infertility” and related terms during NIAW. Interestingly, NIAW did generate similar increases to another established campaign in TCAM, highlighting the difficulty that both campaigns have had in achieving similar success to the gold standard health awareness campaign in BCAM. Several factors suggest NIAW should be able to generate similar success to BCAM. First, like breast cancer, infertility is a highly prevalent disease. An analysis of the National Survey of Family Growth in 2002 demonstrated about 7.3 million women were affected (1), with this number likely rising as society trends towards more delayed childbirth (8). In comparison, recent SEER data estimated there were 3,477,866 women suffering from breast cancer in 2016 (9).  Although these are not identical comparisons, infertility is just as common as breast cancer, yet search interest in this condition is not nearly as high. Second, while awareness campaigns may suffer from an initial lag in success due to the difficulties of initiating a massive nationwide operation, NIAW is well-established, founded in 1989, providing ample time for the program to promote heightened levels of interest and awareness. BCAM was initiated in 1985, and in just one decade, substantial success was achieved (7).

Despite these factors that would seemingly promote the success of NIAW, there are inherent differences in the pathologies of infertility and cancer that may partially explain the limited increase in search volume. First, cancer will often have the benefit of a concrete pathologic diagnosis. Infertility, however, is defined as the inability to achieve a successful pregnancy after 1 year of unprotected regular intercourse. While some patient’s may question their ability to conceive after this defined interval, others may wait much longer before accepting the diagnosis. Likewise, there appears to be a general perception among patients that cancer is a dreaded disease to be treated with urgency (10), yet infertility is often met with a more protracted diagnostic and treatment course, with some couples never seeking treatment altogether (11). These considerations are often exacerbated by perceptions of stigma surrounding the label of infertility (12, 13), which can further delay couples in searching for information on this disease.

There are also stark differences in access to care for these conditions that may contribute to differences in search interest. Universally, cancer treatments are considered essential by society at large, and these treatments are largely covered by most payers. In contrast, coverage of fertility treatments is incredibly variable across payers and geographic regions with only 17 states currently mandating fertility coverage in any form (14). As such, couples with infertility may presume that the financial barriers to care are substantial enough to prevent them from even seeking information regarding their disease. 

 Lastly, simple as it may be, the very duration of these campaigns may contribute to their relative success. The one-week duration for NIAW may be insufficient to generate momentum in the press, social media, and through other avenues. BCAM extends for an entire month, offering greater opportunity to build momentum and raise awareness. Duration alone, however, cannot explain these differences, as TCAM extends for a month and has similar results to NIAW. Indeed, the overall similarity between search volumes during NIAW and TCAM suggests that many of the aforementioned factors (ex: perception of cancer vs infertility) cannot fully explain the observed differences in search volumes.

In aggregate, these results indicate that there is potential room to improve the online footprint for NIAW. One avenue for reaching the target audience is the increased utilization of social media due to its widespread use among those in the age ranges affected by infertility (15). Surveys from infertility clinics demonstrate that the majority of patients felt that social media was a helpful adjunct to the clinical experience (16).  Despite extensive adoption of social media for many movements, however, the conversation surrounding awareness campaigns may not always achieve the stated objectives.  For example, as reported by Bravo et al., online Twitter traffic for the Movember campaign has demonstrated a tendency to discuss mustache growing contests and marketing rather than men’s health and cancer (17).  Although NIAW has embraced social media during its campaign, it is imperative that it is appropriately harnessed to optimally raise awareness.

In addition, future endeavors will almost certainly need to allocate more resources towards certain populations. Prior studies have shown decreased fertility knowledge among patients with lower socioeconomic status and certain ethnic groups  (18, 19). Furthermore, lower income and level of education is associated with lower internet usage (20).  With this in mind, underserved populations may be underrepresented and could benefit the most from increased awareness.  Likewise, men represent another important group that can benefit from NIAW. Male factor infertility is present in approximately half of couples with infertility, yet men demonstrate significantly less fertility knowledge than their female counterparts (2). In general, men utilize fewer health care services compared to women, and the pervasive stigmatization of male infertility has caused many men to feel self-conscious about their condition (12, 21).  In combination, these factors highlight the need to tailor aspects of awareness campaigns towards men, who are inherently more difficult to reach compared to their female partners. This appears to be reflected in the results of TCAM. Even when comparing male and female specific cancers, there was substantially greater search interest in breast cancer than testicular cancer. While this is likely due to many factors, it may underscore the difficulty of raising health awareness specifically in men.

The results of our study must be interpreted within the context of the limitations of Google Trends. First, the platform offers no demographic data, making it impossible to characterize those individuals performing the search. Google Trends also fails to capture those seeking information through other means such as social media, related search terms, or those without internet access. Specifically, NIAW may reach individuals through related search terms such as “IVF”, “male infertility”, or “female infertility” which may not be combined due to limitations of the platform.  Although these terms have a much lower search volume compared to the term “infertility” alone, these terms in aggregate may lead to a substantial rise in search volume.  In addition, the current methodology would not catch those seeking information through direct access of infertility awareness websites which would bypass search engines. Furthermore, despite Google holding the majority market share for internet search queries, Google Trends only captures those using Google as their preferred search engine.  Nonetheless, Google searches do account for 90% of all internet searches, rendering Google Trends a fairly accurate representation of overline online search interest (22).

Conclusion

NIAW is associated with an increase in internet search volume for the term “infertility,” but this was substantially less than the increase for “breast cancer” seen during BCAM.  Many parameters might influence this disparity including inherent differences surrounding the diseases. Although search volume may not be the perfect proxy for public interest, our data suggests there might be additional opportunity for further increases in public awareness of infertility through the NIAW campaign.

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Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders. The journal publishes juried original scientific articles in clinical and laboratory research relevant to reproductive endocrinology, urology, andrology, physiology, immunology, genetics, contraception, and menopause. Fertility and Sterility® encourages and supports meaningful basic and clinical research, and facilitates and promotes excellence in professional education, in the field of reproductive medicine.