School-based vaccination programs are an efficient mechanism for offering protection against a variety of vaccine-preventable diseases to large cohorts of adolescents.1 Historically, such programs have demonstrated both higher vaccine uptake and higher completion rates for a three-dose vaccine than are achieved by traditional vaccine delivery.1,2 This is likely to be due to ease of access, as relatively few adolescents routinely attend medical clinics compared with other age groups.2 Currently, Australia, Canada and the United Kingdom are offering school-based delivery of human papillomavirus (HPV) vaccine to adolescent girls, and European countries are considering or launching school-based programs.3 Some countries have concerns about the acceptability to parents of mass school-based vaccination against HPV.4
During the early implementation phase of HPV vaccination in Australia, reports of fainting and of mass psychogenic reactions were widely publicised internationally.5,6 Fear of vaccination, including fear of pain, was also noted in a pilot study in the UK.7 Fear and collective distress in response to a perceived threat can cause headache, fatigue, hyperventilation and syncope, and females are disproportionately affected.6 Symptoms can spread quickly by “line-of-sight” transmission.6 Such responses are not uncommon in school settings8,9 and could adversely affect attitudes toward and acceptance of HPV vaccination.
Fear and distress caused by vaccination have been assessed in children,10 but not in adolescents. Mass vaccine delivery to adolescents in a school setting presents additional challenges; fear may heighten or spread as a result of rumours distorting the threat of the vaccine.5
As part of a larger study that aimed to examine experiences, decision making and factors influencing consent and vaccination uptake in the 2008 and 2009 HPV school-based vaccination program in New South Wales,11-13we present data pertaining to the experience of and response to fear, among adolescent girls being offered HPV vaccination.
A purposive sampling strategy was used to approach potential participants from a broad range of vaccination experiences, including those fully vaccinated, incompletely vaccinated and not vaccinated. To facilitate this, schools with high and low vaccination uptake, determined by data from the 2007 vaccination program, and schools from different sectors (public, Catholic and independent) across Sydney were approached. Ten schools were contacted and nine elected to participate; the 10th was unable to accommodate our research within the school year. The participating schools had three-dose vaccine completion rates ranging from 64% to 90% of all eligible girls.
The study was formally approved by the human research ethics committee at the Children’s Hospital at Westmead and the NSW Department of Education and Training research approval board. In addition, the study was supported by the Association of Independent Schools in NSW and the relevant local Catholic Diocese.
A subsample of three schools was selected for observation on vaccination days. Two researchers visited two school sites each, conducting a lone and a joint observation each, for a total of three observations. Their observations described the context, which included the environment, procedures and processes, and comments of students, teachers and nurses.
Focus groups and interviews were digitally recorded, transcribed verbatim, and analysed using the qualitative software package QSR NVivo 7 (QSR International, Melbourne, Vic). Two of us (D M B, S C C R) completed the primary analysis, using an inductive approach and constant comparison.14 Conceptual saturation was reached when no new codes were generated.15 Details of our analytical approach have been published previously.11
Data from observing three schools and from interviewing 130 adolescents in 20 focus groups, 38 parents, 10 teachers and seven nurses were included in our analysis (Box 1). Quotations given in the following sections are followed by code letters denoting schools, and the number of the focus group (FG) or nurse interview (N).
Fear was a common emotion experienced with regard to vaccination. The girls’ fear consisted of three main features: fear of pain, fear of having the needle pierce the skin, and fear of vaccine content and possible side effects. Parents were often aware of their daughters’ fear and some had discussed it with their daughters. Other parents did not have a discussion or expected the school to address this issue.
Girls, parents, teachers and nurses all discussed the intense fear response of some girls to vaccination. Our observations supported statements that some students experienced a more severe reaction than others, which included sobbing, screaming, and fainting. One adolescent’s intense reaction seemed to lead to others experiencing this same intensity.
Factors both promoting and mitigating fear were identified; some factors influenced fear in more than one direction (Box 2).
Use of privacy screens and the number of girls waiting in an area before vaccination were important procedural factors.
Concern among girls about their possible reactions in front of their peers seemed to amplify fear in some cases.
A few girls who had read the parent information brochure said that reading about possible side effects made them more fearful.
I know the side effects are, like, good to have on the sheet so it can warn you, but then when girls heard about it they got even more scared. (D, FG 2)
Many girls discussed the benefit of having their friends available in the room to support them by holding their hand or talking to them.
Girls discussed distraction techniques that nurses used and how these helped to make the girls feel more comfortable.
It’s better when [the nurses] talk to you because then you’re distracted . . . They had some balls and they gave you one of those to squeeze and you didn’t feel the needle going in. (E, FG 2)
Girls in a selection of schools reported how negative interactions with nurses increased their fear.
Our observations indicated that girls who were vaccinated in the morning were calmer on entry to the vaccination room than those vaccinated later in the day. In the afternoon, many girls were sobbing even before entering the room. This appeared to be due to conversations held while they waited: about whether the vaccination was painful, girls having fainted and certain nurses having caused more pain than others. As the day and rumours progressed, many girls’ fear increased. Additionally, the time taken for nurses to vaccinate each girl lengthened over the course of the day.
Our results suggest that anxiety related to vaccination at school is commonplace for adolescent girls, and this was evident for HPV vaccination.
While anticipatory fear is associated with vaccination in other settings,16 anticipatory and experienced fear may be particularly intense for girls vaccinated in a school setting. Severe responses, such as mass psychogenic reactions that have been seen in mass vaccination settings,6,17-20 were not noted in our study. Our data suggest that when anxiety and fear were at increased levels, the process of vaccination either slowed or did not occur.
In this study, fear seemed to be linked to anticipatory anxiety, which can be an important predictor of perceived pain in children and adolescents.21 Fear of the needle piercing the skin, watching a nurse prepare an injection, and observing others receiving injections have been associated with increased anxiety in other settings.16
Methods of soothing younger children receiving venepuncture include having a parent present,22 but our research suggests that in school-based vaccination, appropriate peer support may assist some girls. Peers are extremely important for adolescent girls as a source of support and as a preferred resource for dealing with health concerns.23,24
Other effective interventions used for management of pain and distress are distraction and cognitive behaviour interventions.25-27 Our research indicated that wider use of distraction methods, such as allowing girls to listen to iPods, could be effective.
A nurse’s approach while providing vaccination can affect a vaccine recipient’s response. An empathic approach elicits more positive behavioural responses than a directive approach.28 This supports our study’s findings that girls’ perceptions of the nurses’ approach contributed to their experience. It may be appropriate for some vaccination nurses to receive training in managing adolescents’ fears related to vaccination.
Preparation for injections and vaccinations can result in lowered perceptions of pain.29 Our data suggest that being informed and well prepared may reduce the propagation of myths, rumours and other fear-promoting factors. This would then reduce fear and, potentially, refusals of vaccination. Appropriate education for girls, either through discussions with parents, teachers and nurses, or through specifically designed educational and self-management strategies, may provide adolescents with a more positive experience of vaccination.
Anticipatory fear is a normal response to a perceived threat,30 but is an unnecessary psychological trauma when no real threat exists. Vaccination providers have a clinical, moral and ethical obligation to minimise the anxiety and pain associated with vaccine delivery.31,32 Guidelines have prioritised preventing and treating procedural pain and anxiety related to medical procedures in children and adolescents.33 Given the nearly universal finding of fear in this study, these should be priorities for school HPV vaccination programs. Mitigating girls’ experience of fear is likely to promote acceptance of the vaccine and improve the efficiency of the vaccination process. Promoting higher levels of understanding, offering peer support, and careful examination of procedural factors that alleviate distress during vaccination at school should be considered, particularly as school-based vaccination becomes more common internationally.
Received 10 August 2010, accepted 19 December 2010
Abstract
Objectives: To examine the experience of fear, the fear response, and factors affecting fear in adolescents undergoing school-based human papillomavirus (HPV) vaccination.
Design, participants and setting: A purposive sampling strategy and qualitative methods, including observation and face-to-face interviews. Focus groups comprised adolescent girls who were involved in HPV vaccination in 2007 at schools in Sydney, New South Wales. Individual interviews were conducted with parents, teachers and vaccination nurses.
Results: Data from observing vaccination days at three schools and from interviewing 130 adolescents in 20 focus groups, 38 parents, 10 teachers and seven nurses were included in the analysis. All participants discussed the issue of fear and distress experienced by adolescent girls in relation to HPV vaccination. Observations corroborated the focus group and interview data. Our results indicated that fear was promoted by witnessing the fear reactions of peers; perceived judgement by peers; lack of information or misinformation; and being vaccinated later in the day. Fear was moderated by procedural factors, the support of peers, appropriate knowledge, and nurses’ distraction techniques or approach. Fear also affected acceptance of HPV vaccination.
Conclusions: Fear of HPV vaccination was a near universal experience among adolescents in the school setting and was often associated with significant distress that had an adverse impact on the vaccination process. School vaccination could be improved by proactively managing fear and distress.