Risk, choice and the ‘girl vaccine’: Unpacking human papillomavirus (HPV) immunisation

The needle pricking and two modes of 'doing good' in the Swedish school-based human papillomavirus vaccination programme

In this article, we draw on science and technology studies literature on care practices to analyse school nurses' work with human papillomavirus (HPV) vaccination in schools, in the context of a new vaccination policy including all children in the fifth grade in Sweden. Drawing on 21 interviews with school nurses working in municipalities across a larger Swedish region, we focus on the mundane work of handling the vaccination and supporting the children while they are being vaccinated. We utilise the notion of 'modes of doing good' to analyse routines and ideals oriented towards specific, and sometimes contradictory, forms of 'good care' in HPV vaccination practice. Two modes of doing good are identified: the vaccination as a caring for 'the flow' of children getting vaccinated and the vaccination as a caring about the specific child. We analyse three 'child subjects' alongside these modes: the informed and already prepared child, the anxious child, and the specific child. By identifying tensions and interferences between different child subjects and modes of doing good, we discuss possible consequences of our findings for how HPV vaccination is envisioned and conceptualised in social science research and in policy settings.

From knowledge to a gendered event and trustful ties: HPV vaccine framings of eligible Finnish girls and school nurses

In the present study, we examine socio-cultural and practical aspects of human papillomavirus vaccination (HPVV) through a multi-sited study of framings. We ask how HPVV is framed in the daily lives of vaccination-aged Finnish girls and in school nurses' everyday work. We then mirror these framings against both each other and Finland's official vaccination campaign. Based on analysis of interviews with 24 nurses and 12 girls and the campaign materials, we argue first that the campaign frames vaccination as an individual, knowledge-based decision reflecting the informed consent principle. Second, however, the vaccination is framed in the everyday lives of eligible girls through gendered social ties and as a gendered and cohort-specific event pivoting around the needle prick. Third, HPVV is not primarily framed in the school nurses' work as preparing the girls for the vaccination decision by sharing official information but through trust-based social relationships with the girls and their parents. We conclude that, as the vaccination is not an issue of individually reflected and knowledge-based decision-making for the two interviewed key groups, the official Finnish HPVV campaign and the undergirding informed consent principle drift into problems in their practical implementation.

Vaccination discourses among chiropractors, naturopaths and homeopaths: A qualitative content analysis of academic literature and Canadian organizational webpages

Vaccine hesitancy–the reluctance to receive recommended vaccination because of concerns and doubts about vaccines–is recognized as a significant threat to the success of vaccination programs and has been associated with recent major outbreaks of vaccine-preventable diseases. Moreover, the association between complementary and alternative medicine (CAM) use and vaccine hesitancy and/or refusal has been frequently reported in the literature. To date, significant gaps persist in our understanding of contemporary Canadian CAM providers’ beliefs regarding vaccination and how socio-professional influences may shape their vaccine-related attitudes and behaviours. To address the latter gap, the current study aims to explore the content of professional guidelines, recommendations and other discourses among CAM providers as they concern vaccination by analyzing both academic, peer-reviewed literature and Canadian organizational webpages prepared by and/or for practicing chiropractors, naturopaths and homeopaths. In the academic literature, we identified a number of complex and diverging views on vaccination that spanned topics of effectiveness; safety; theoretical, empirical, and ethical soundness; political justifiability; and compatibility with CAM philosophy and professional boundaries. However, in its current state the CAM literature cannot be described in broad strokes as being either pro- or anti-vaccination without considering finer areas of disagreement. Compared to the academic literature, which focuses more on the conceptual and evidentiary basis of vaccination, a greater proportion of vaccine-related content on Canadian CAM organizations’ webpages seems to be dedicated to offering specific directives and prescriptions to providers. Guidelines and standards of practice address a number of issues, including vaccine administration, counsel, education and marketing. As CAM organizations further evolve in Canada and elsewhere as part of a broader “professionalization” initiative, greater attention will need to be directed at their role in shaping providers’ beliefs and practices that both support and undermine vaccine promotion efforts.

When risk becomes illness: The personal and social consequences of cervical intraepithelial neoplasia medical surveillance

Background

After the early detection of cervical intraepithelial neoplasia (CIN), medical surveillance of the precancerous lesions is carried out to control risk factors to avoid the development of cervical cancer.

Objective

To explore the effects of medical surveillance on the personal and social lives of women undergoing CIN follow-up and treatment.

Methodology

A generic qualitative study using a poststructuralist perspective of risk management was carried out in a gynecology clinic in a public hospital of the Galician Health Care System (Spain). Participants were selected through purposive sampling. The sample consisted of 21 women with a confirmed diagnosis of CIN. Semistructured interviews were recorded and transcribed, and a thematic analysis was carried out, including researcher triangulation to verify the results of the analysis.

Findings

Two main themes emerged from the participants’ experiences: CIN medical surveillance encounters and risk management strategies are shaped by the biomedical discourse, and the effects of “risk treatment” for patients include (a) profound changes expected of patients, (b) increased patient risk management, and (c) resistance to risk management. While doctors’ surveillance aimed to prevent the development of cervical cancer, women felt they were sick because they had to follow strict recommendations over an unspecified period of time and live with the possibility of a life-threatening disease. Clinical risk management resulted in the medicalization of women’s personal and social lives and produced great uncertainty.

Conclusions

This study is the first to conceptualize CIN medical surveillance as an illness experience for patients. It also problematizes the effects of preventative practices in women’s lives. Patients deal with great uncertainty, as CIN medical surveillance performed by gynecologists simultaneously trivializes the changes expected of patients and underestimates the effects of medical recommendations on patients’ personal wellbeing and social relations.

HPV vaccination in Papua New Guinea to prevent cervical cancer in women: Gender, sexual morality, outsiders and the de-feminization of the HPV vaccine

Papua New Guinea has among the highest estimated burden of cervical cancer globally, but currently lacks national cervical screening or human papillomavirus (HPV) vaccination programmes. The Papua New Guinean government is committed to introducing the HPV vaccine for primary prevention, but locally-relevant research evidence is not available to guide implementation. Experience from earlier Papua New Guinean health programmes suggests that appropriate engagement with local health cosmologies and cultures for health/wellbeing, illness/disease, and recognition of the role of ‘outsiders’ in preventing, promoting or contributing to sickness, are essential to the successful introduction of biomedical interventions in this setting. We describe findings from a multi-site qualitative study undertaken in three provinces in Papua New Guinea (2012-14). Twenty-one gender specific focus group discussions and 82 semi-structured interviews, with a total of 208 participants, were conducted. There was strong community support for the introduction of the HPV vaccine for cervical cancer prevention in Papua New Guinea. Significantly, and despite being officially discussed in the context of a planned future intervention focusing on vaccinating young girls to prevent cervical cancer, the intervention was de-feminised, where both girls and boys were supported to be vaccinated in any HPV programme in Papua New Guinea.

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First study of HPV vaccine acceptability in Papua New Guinea and the Pacific.

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Evidence of strong support for the vaccination of both girls and boys against HPV in Papua New Guinea.

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Local beliefs and concerns about HPV immunisation may impact acceptability in Papua New Guinea.

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Suspicion of Western medicine and health care workers reported in rural areas.

What kind of 'a girls' thing'? Frictions and continuities in the framing and taming of the HPV vaccine in Finland

This article focuses on two different ways of framing and taming the uncertainties of the human papillomavirus (HPV) vaccine in the context of the Finnish welfare state: the bio-medical rationale of population-level cancer reduction based on epidemiological assessments, and the meaning formation of Finnish vaccination-aged girls. Epidemiologists run analyses estimating the cost-effectiveness and public health benefit of vaccinations, while the adolescent girls face the burdensome choice of whether to undergo vaccination. The processes of framing the complexities and actively taming them are analysed utilising a cultural-sociological framework. Firstly, the taming work of the epidemiologists is examined by focusing on the creation of the vaccination campaign. The aetiological complexities between some HPV types and cervical cancer are tamed into a clear campaign message of vaccination as a scientifically proven protection against deadly cancer. Secondly, the girls' own ways of framing the complexities of the HPV vaccine and taming the decision whether to undergo vaccination or not are analysed based on their comments in an Internet discussion forum. Finally, the framings and tamings of both sites are discussed together, and some interesting continuities and disjunctions between the two are revealed.

HPV vaccination discourses and the construction of "at-risk" girls

RéSUMé: OBJECTIF: L'objectif était d'étudier le déploiement des discours sur la vaccination contre les VPH (VVPH) et leur impact sur les filles, les parents, les infirmiers/infirmières et les médecins canadiens. MéTHODES: Des entrevues ont été réalisées avec des participant(e)s (n = 146) de quatre provinces canadiennes. Une analyse poststructuraliste du discours a permis d'examiner les campagnes de VVPH et les transcriptions d'entrevues pour documenter la façon dont les participant(e)s interprètent les VVPH et se positionnent comme sujets au sein des discours de l'industrie ou des agences de santé publique. RéSULTATS: Les campagnes de VVPH sont sexistes, hétéro-normatives et trompeuses. Émergeant de l'analyse des entrevues est le manque d'information des filles et des parents en ce qui a trait à la VVPH. Les mères se construisent en tant que bio-citoyennes responsables, mais au prix de l'impuissance, de l'anxiété et de la peur ressenties parallèlement à l'impératif d'agir pour minimiser le risque de cancer de leur fille. Quant aux professionnel(le)s de la santé, ils s'approprient les discours dominants sur la VVPH et utilisent la peur comme stratégie pour fabriquer le consentement pour la VVPH. Les occasions de dialogue sur la VVPH et la santé sexuelle des filles sont perdues et les positions en tant que sujets sont problématiques pour tous les types de participant. CONCLUSIONS: Nous nous questionnons à savoir si la santé publique est bien servie quand les discours sur la VVPH transforment des corps en santé en corps « à risque » et quand la peur du cancer est instrumentalisée pour la pharmacologisation de la santé publique.

The sociology of cancer: a decade of research

Biomedicine is often presented as the driving force behind improvements in cancer care, with genomics the latest innovation poised to change the meaning, diagnosis, treatment, prevention and lived experience of cancer. Reviewing sociological analyses of a diversity of patient and practitioner experiences and accounts of cancer during the last decade (2007-17), we explore the experiences of, approaches to and understandings of cancer in this period. We identify three key areas of focus: (i) cancer patient experiences and identities; (ii) cancer risk and responsibilities and (iii) bioclinical collectives. We explore these sociological studies of societal and biomedical developments and how sociologists have sought to influence developments in cancer identities, care and research. We end by suggesting that we extend our understanding of innovations in the fields of cancer research to take better account of these wider social and cultural innovations, together with patients, activists' and sociologists' contributions therein.

Putting public health infrastructures to the test: introducing HPV vaccination in Austria and the Netherlands

This article presents two cases of policymaking concerning the vaccine against Human Papilloma Virus (HPV), which is sexually transmitted and carcinogenic. Our analysis focuses on its introduction in Austria and the Netherlands. In both contexts, we find prevention and screening to be at once complementary and competing public health logics and we draw on the concept of 'infrastructure' to understand their roles in shaping the reception of the vaccine. We reveal how the HPV vaccine had to be made 'good enough', much like the Pap smear (Casper and Clarke ), by means of diverse tinkering practices that transformed both the technology and the infrastructures in which they emerged. At the same time, it was important that the vaccine would not come to problematise Pap smear-based screening. The article points to the contextually contingent nature of policymaking around new medical technologies, and the skillful care with which public health infrastructures such as immunisation and screening programmes are handled and tinkered with.

Measuring vaccine acceptance among Canadian parents: A survey of the Canadian Immunization Research Network

Parental decision making about childhood vaccinations is complex and multidimensional. There is a perception that the number of parents having concerns regarding childhood vaccinations has been increasing in Canada. The aim of this study was to explore vaccine hesitancy among Canadian parents and to examine factors associated with a parent's intention to vaccinate his/her child. Informed by the Theory of Planned Behaviour (TPB) this study assesses potential associations between parents' knowledge, attitudes and beliefs toward vaccination and their intention to vaccinate their child in the future. A national sample of Canadian parents of children aged 24-59 months (N = 2013) was surveyed using an online survey methodology. Half of the surveyed parents strongly intended to have their child vaccinated in the future. Parents' information needs and searches as well as parents' trust in different institutions were associated with intention to vaccinate. Parents who reported having frequently looked for vaccine information, who considered that it was their role as parents to question vaccines, or who had previously experienced difficulty accessing vaccination services were less likely to strongly intend to vaccinate their child in the future. Parents who had a high level of trust in doctors and public health were most likely to strongly intend to vaccinate their child. Results of the multivariate analysis showed that positive attitudes (aOR = 8.0; 95% CI: 6.0, 10.4), higher perceived social support (aOR = 3.0; 95% CI: 2.3, 3.93), and higher perceived behavioural control (aOR = 1.8; 95% CI: 1.4, 2.43) were associated with parents' intention to vaccinate their child. Findings of this study suggest that trust-building interventions that promote pro-vaccine social norms and that address negative attitudes toward vaccination could enhance vaccine acceptance among Canadian parents.

"One of the greatest medical success stories:" Physicians and nurses' small stories about vaccine knowledge and anxieties

In recent years, the Canadian province of Alberta experienced outbreaks of measles, mumps, pertussis, and influenza. Even so, the dominant cultural narrative maintains that vaccines are safe, effective, and necessary to maintain population health. Many vaccine supporters have expressed anxieties that stories contradicting this narrative have lowered herd immunity levels because they frighten the public into avoiding vaccination. As such, vaccine policies often emphasize educating parents and the public about the importance and safety of vaccination. These policies rely on health professionals to encourage vaccine uptake and assume that all professionals support vaccination. Health professionals, however, are socially positioned between vaccine experts (such as immunologists) and non-experts (the wider public). In this article, I discuss health professionals' anxieties about the potential risks associated with vaccination and with the limitations of Alberta's immunisation program. Specifically, I address the question: If medical knowledge overwhelmingly supports vaccination, then why do some professionals continue to question certain vaccines? To investigate this topic, I interviewed twenty-seven physicians and seven nurses. With stock images and small stories that interviewees shared about their vaccine anxieties, I challenge the common assumption that all health professionals support vaccines uncritically. All interviewees provided generic statements that supported vaccination and Alberta's immunisation program, but they expressed anxieties when I asked for details. I found that their anxieties reflected nuances that the culturally dominant vaccine narrative overlooks. Particularly, they critiqued the influence that pharmaceutical companies, the perceived newness of specific vaccines, and the limitations of medical knowledge and vaccine schedules.

Ambiguous Capture: Collaborative Capitalism and the Meningitis Vaccine Project

The primary health care approach advanced at Alma Ata to address social determinants of health was replaced by selective health care a year later at Bellagio. Subsequently, immunization was endorsed as a cost-effective technical intervention to combat targeted infectious diseases. Multilateral efforts to collaborate on immunization as a universal public health good ambiguously capture the interests of the world's governments as well as private, public, and not-for-profit institutions. Global assemblages of scientists, governments, industry and nongovernmental organizations now work in public-private partnerships to develop and make essential vaccines accessible, with vaccines marketed as single fix solutions for global health. Drawing from ethnographic fieldwork in France and Burkina Faso that followed the development, regulation, and implementation of the group A meningococcal conjugate vaccine for sub-Saharan Africa, in this article I describe events during and after the development of MenAfriVac. A technological success narrative steeped in collaborative capitalist rhetoric disguises neglected health care systems.

"Saving lives": Adapting and adopting Human Papilloma Virus (HPV) vaccination in Austria

Vaccination against the sexually transmitted Human Papilloma Virus (HPV), a necessary agent for the development of cervical cancer, has triggered much debate. In Austria, HPV policy turned from "lagging behind" in 2008 into "Europe's frontrunner" by 2013. Drawing on qualitative research, the article shows how the vaccine was transformed and made "good enough" over the course of five years. By means of tinkering and shifting storylines, policy officials and experts disassociated the vaccine from gender, vaccine manufacturers, and youth sexuality. Ultimately, the HPV vaccine functioned to strengthen the national immunization program. To this end, preventing an effective problematization of the extant screening program was essential.

An appraisal of theoretical approaches to examining behaviours in relation to Human Papillomavirus (HPV) vaccination of young women

BACKGROUND

Interventions to increase uptake of Human Papillomavirus (HPV) vaccination by young women may be more effective if they are underpinned by an appropriate theoretical model or framework. The aims of this review were: to describe the theoretical models or frameworks used to explain behaviours in relation to HPV vaccination of young women, and: to consider the appropriateness of the theoretical models or frameworks used for informing the development of interventions to increase uptake.

METHODS

Primary studies were identified through a comprehensive search of databases from inception to December 2013.

RESULTS

Thirty-four relevant studies were identified, of which 31 incorporated psychological health behaviour models or frameworks and three used socio-cultural models or theories. The primary studies used a variety of approaches to measure a diverse range of outcomes in relation to behaviours of professionals, parents, and young women. The majority appeared to use theory appropriately throughout. About half of the quantitative studies presented data in relation to goodness of fit tests and the proportion of the variability in the data.

CONCLUSION

Due to diverse approaches and inconsistent findings across studies, the current contribution of theory to understanding and promoting HPV vaccination uptake is difficult to assess. Ecological frameworks encourage the integration of individual and social approaches by encouraging exploration of the intrapersonal, interpersonal, organisational, community and policy levels when examining public health issues. Given the small number of studies using such approach, combined with the importance of these factors in predicting behaviour, more research in this area is warranted.

A feminist information engagement framework for gynecological cancer patients

Purpose

– The purpose of this paper is to present a three-part framework of information engagement for situated gynecological cancers. These particular cancers intertwine with medicalization of sexuality and gender power dynamics, situating information behaviors and interactions in women’s socio-health perceptions. Using Kavanagh and Broom’s feminist risk framework, the framework establishes functional and temporal parameters for sense-making and information engagement.

Design/methodology/approach

– This paper employs a structured, reiterative literature review with emergent thematic analysis. Nine indices from medicine, information studies, and sociology were searched using combinations of five terms on cervical cancer (CC) and 14 terms on information engagement in the title, abstract, and subject fields. Results were examined on a reiterative basis to identify emergent themes pertaining to knowledge development and information interactions.

Findings

– Environmentally, social stigma and gender roles inhibit information seeking; normalizing CC helps integrate medical, moral, and sexual information. Internally, living with the dichotomy between “having” a body and “being” a body requires high-trust information resources that are presented gradually. Actively, choosing to make or cede medical decision-making requires personally relevant information delivered in the form of concrete facts and explanations.

Research limitations/implications

– The study covers only one country.

Originality/value

– This study’s information framework and suggestions for future research encourage consideration of gender power dynamics, medicalization of sexuality, and autonomy in women’s health information interactions.

Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis

BACKGROUND

Vaccination against Human Papillomavirus (HPV) is recommended for adolescent young women prior to sexual debut to reduce cervical cancer related mortality and morbidity. Understanding factors affecting decision-making of HPV vaccination of young women is important so that effective interventions can be developed which address barriers to uptake in population groups less likely to receive the HPV vaccine.

METHODS

We undertook a qualitative systematic review and evidence synthesis to examine decision-making relating to the HPV vaccination of young women in high-income countries. A comprehensive search of databases from inception to March 2012 was undertaken to identify eligible studies reporting the perspectives of key stakeholders including policy makers, professionals involved in programme, parents, and young women. Factors affecting uptake of the vaccine were examined at different levels of the socio-ecological model (policy, community, organisational, interpersonal and intrapersonal).

RESULTS

Forty-one studies were included. Whether young women receive the HPV vaccine is strongly governed by the decisions of policy makers, healthcare professionals, and parents. These decisions are shaped by: financial considerations; social norms and values relating to sexual activity, and; trust in vaccination programmes and healthcare providers. Financial constraints may be overcome through universal healthcare systems offering the HPV vaccine free at the point of delivery. In the healthcare setting, judgements by healthcare professionals about whether to recommend the vaccine may restrict a young woman's access to the vaccine irrespective of her own beliefs and preferences. Parents may decide not to allow their daughters to be vaccinated, based on cultural or religious perceptions about sexual activity.

CONCLUSIONS

Barriers to the uptake of the HPV vaccine have implications for young women's future sexual, physical and reproductive health. Interventions to address barriers to uptake of the vaccine should target appropriate, and multiple, levels of the socio-ecological model. Issues of trust require clear, accessible, and sometimes culturally appropriate, information about the HPV vaccination programme. Although young women are central to the HPV vaccination programme, their views are underrepresented in the qualitative literature. Future research should consider young women's perceptions of, and involvement in, consent and decision-making.

Interest in having HPV vaccination among adolescent boys in England

BACKGROUND AND PURPOSE

The United States' Centers for Disease Control and Prevention recommends that boys aged 11-12 be vaccinated against HPV to reduce the risk of genital warts and HPV-related cancers. No recommendation has been made in England although there have been calls to widen access to the vaccine. This study aimed to assess boys' willingness to have HPV vaccination, eliciting reasons for their decisions.

METHODS

528 boys aged 16-18 years completed a questionnaire in school. Measures included demographic characteristics, HPV awareness, willingness to have the vaccine, and reasons for the vaccine decision. Coding of open responses was informed by social cognition model constructs.

RESULTS

A large proportion of the sample (41%) intended to have the vaccine, however, slightly more were unsure (49%) and a small number (10%) would not get vaccinated. Uncertainty was associated with lack of previous awareness of HPV and perceived lack of adequate information. Boys who would not have the vaccine did not feel at risk or did not see the need for it.

CONCLUSION

These preliminary data suggest that HPV vaccination may be acceptable to boys, and confirm previous findings that information is vital in the decision-making process.