Abstract
Expectations prior to needle-related procedures can influence individuals’ decision making and compliance with immunization programmes. To protect from human papilloma virus (HPV) and cervical cancer, the immunization needs to be given before sexual debut raising interest for this study’s aim to investigate how 11 to 12-year-old girls narrate about their expectations prior to HPV vaccination. A total of 27 girls aged 11 to 12 years participated in this qualitative narrative study by writing short narratives describing their expectations. The requirement for inclusion was to have accepted HPV vaccination. Data were subjected to qualitative content analysis. Findings showed the following expectations: going to hurt, going to be scared and going to turn out fine. The expectations were based on the girls’ previous experiences, knowledge and self-image. The latent content revealed that the girls tried to transform uneasiness to confidence. The conclusion drawn from this study is that most girls of this age seem confident about their ability to cope with possible unpleasantness related to vaccinations. However, nurses need to find strategies to help those children who feel uneasy about needle-related procedures.
Introduction
It is common that children and youth find procedures aimed to diagnose, treat and prevent diseases painful, unpleasant and frightening (Forsner et al., 2009; Nilsson et al., 2013). Many children have severe discomfort associated with vaccinations and risk developing needle phobia (Taddio et al., 2009). In a study of 1000 children, fear of needles was found in 63% of the children (Taddio et al., 2012). Topical analgesia as well as distraction techniques such as guided imagery is known to decrease paediatric procedural pain and anxiety (Uman et al., 2013); however, this is rarely offered prior to vaccinations (Taddio et al., 2009).
Introduction of vaccination against human papilloma virus (HPV) dramatically reduced the prevalence of the infection in Sweden (Soderlund-Strand et al., 2014) and, when offered to all girls before sexual debut, is assumed to prevent as much as 75% of cases of cervical cancer (Leval et al., 2013). In Sweden the school-based vaccination programme includes HPV vaccination consisting of three doses administered to girls aged 11 to 12 years. Even though the uptake is high, statistics from the Public Health Agency of Sweden (2014) showed that in the past year, 18% did not receive even the first dose.
According to the UN General Assembly (1989), children have the right to participate in matters that affect them; hence, children’s own preferences in healthcare situations are of interest (Coyne and Harder, 2011). In a 12 to 19-year-old German female population, 67% had received HPV vaccination but only 41% had had all three recommended doses. Parents and doctors influenced the girls’ decision, but personal beliefs also played a major role (Stocker et al., 2013). In the United States, at an adolescent primary care setting, both children and the accompanying adult demonstrated good knowledge about vaccination; however, for adults, the notion that their child was too young to risk sexually transmitted diseases influenced the decision whilst the pain bothered the children (Benin et al., 2010). American mothers reported that the decision about the HPV vaccination primarily rested on them as parents, although their adolescent daughters reported it to be mutual (Griffioen et al., 2012).
When children were asked about their experiences of pain in hospital, it became clear that earlier experiences were of importance for upcoming procedures (Polkki et al., 1999). The basis for decisions about HPV vaccination has been investigated through interviews with the child and parents together (Griffioen et al., 2012) and separately (Benin et al., 2010). In two studies, 12-year-old children retroactively wrote about expectations as well as the experience of a needle-related procedure (Forsner et al., 2013; Nordyke et al., 2010); however, when recalling expectations, these were seen in the light of the experience. Hence, it would be of interest to explore children’s expectations prior to procedures involving needles when the experience is in the future and without influence from an interviewer. Therefore, this study’s aim was to investigate how 11 to 12-year-old girls narrate about their expectations prior to HPV vaccination.
Method
Grounded in the assumption that narratives bear meaning including thoughts, beliefs and expectations (Riessman, 2008), a qualitative narrative design was chosen to capture the girls’ expectations.
Participants
Forty girls aged 11 to 12 years were invited to participate in this study in conjunction with a vaccination programme against HPV. They were recruited from three different schools in a large town in Sweden. After acceptance of the vaccination, 27 girls, all fluent in the Swedish language, participated in the study by producing the required narratives.
Data collection
To gain information about the girls’ expectations prior to vaccination, written stories were collected approximately 2 weeks before the vaccination. Written data collection gives information about children’s thoughts and emotions (Carney et al., 2003).
Analysis
The stories were handwritten and later transcribed to a Word file. The text was subjected to qualitative content analysis (Graneheim and Lundman, 2004). All the narratives were read through to get an overall view and preliminary understanding of the data. The text was then divided into content areas and, further, into meaning units, which were condensed, coded and categorized. During the analysis, an underlying meaning emerged, formulated as a theme, an interpretation of the latent content of the text as a whole. The analysis was not linear but went back and forth from the whole to the parts in discussions between all co-authors. The findings are illustrated with quotes from the narratives that were carefully translated from Swedish to English by a qualified translator.
Procedure
This study was part of an intervention evaluating the effect of guided imagery during vaccination with both quantitative measures and repeated narratives. Further findings will be presented in forthcoming articles. The girls were contacted together with their parents. Approximately 3 weeks before the vaccination, they received written information about the study, together with information about the vaccination. Two letters were sent for each girl invited to participate, one to the girl and one to her parents. The letters contained information about the study, a request to the girl to participate and a consent form where both parents were asked for written consent. Voluntariness was ensured. Furthermore, the letter to the girls contained a coded A4 story sheet and a prepaid envelope with a request to send in their story before the vaccination. On the story sheet, they were asked to tell their age and to narrate about how they expected the vaccination to turn out. Most of the sheet offered space for the narrative but additionally they were encouraged to add paper, if they needed more space to tell their story.
Ethical considerations
It is not unproblematic involving children in research projects. For instance, they might feel obligated to participate in a study when approached by an adult researcher. In Sweden, parental approval is needed before the age of 15. At the same time, it is important to explore children’s life conditions and not to exclude children from research projects. Consequently, there are arguments for asking children to participate in research projects concerning themselves (Miller, 2000). In this particular study, the girls voluntarily participated by providing a narrative, and the parents were asked for consent. The study was approved by the head of school health and the regional ethical review board in Gothenburg (Dnr 466-12).
Findings
The data were found to be distributed over two content areas, namely, expectations and what expectations are based on, with three categories for each area. In addition, the following theme describing latent content was formulated, ‘transforming uneasiness to confidence’.
Expectations
A prominent content area in the narratives related to the expectations prior to vaccination. Three categories emerged: going to hurt, going to be scared and going to turn out fine. These expectations were combined and often contrasting.
Going to hurt
Nearly all of the girls used words expressing pain in their narratives about their expectations prior to vaccination, ranging from ‘light pain’ to ‘really painful’, with pain intensity as well as duration mentioned. Some expected the injection to feel like a little sting and to soon fly over: ‘This may sting a little, but I think it will go away quickly’ (17). Others wrote that they expected the vaccination to hurt quite a lot: ‘I think it’s going to hurt a lot but I don’t really know how much’ (12). Furthermore, the pain at the location of the injection was described, but pain was also expected in other parts of the body: ‘I think I’m going to have some stomach ache’ (23).
Going to be scared
Words expressing anxiety and fear related to shots and assurance of not being afraid ranged from ‘a little scared’ to ‘very afraid’. Statements often combined fear with pain.
Feeling uneasy in relation to the vaccination procedure sometimes was expected to lead to reactions surprising the child herself. Whenever I have to get a needle I giggle because I’m uncomfortable. I think that’s a bit weird. (4)
Going to turn out fine
The narratives gave an impression that mostly the vaccination was expected to turn out fine. Even if the procedure was expected to be an inconvenience, the girls hoped to manage. As one example, the caring intervention guided imagery, which was offered during the vaccination, brought hope about eased pain: ‘It will be fun to test the Daydream and see if it dulls the pain’ (11). The hope to manage was further demonstrated in neutral descriptions about what was expected to happen. I go in, sit down on the bench and wait for the needle to go into my arm. Then I’ve had my shot and I can go. (3)
Wishful thinking and self-pep talk seemed to give positive expectations: ‘I think it will go great’ (14) and ‘… a little nervous, but I’m hoping it will be fine’ (8).
The disease was perceived as more scary than the injection, so it was worth putting up with some inconvenience in exchange for health benefits gained: ‘… I’m feeling a bit tense and I think it will be worth the sting’ (24). Furthermore, the expected relief when the procedure was over meant additional positive expectations: ‘I’ll be happy when it’s over, obviously’ (4).
What expectations are based on
The narratives additionally gave an idea about what the expectations were based on: the girls’ previous experiences, their knowledge and their self-image. It appeared to be possible to combine contrasting bases for the expectations, so it was not always easy to follow the girls’ reasoning. For example, one girl reported less pain from her last needle-related procedure but told that she expected to be very afraid this time.
Previous experiences
Previous experiences could have both a positive and a negative influence. To some girls, past experiences reassured them that they would manage fine: ‘I think the vaccination will go fine, ‘cause I’ve had lots of shots before’ (19). For others, previous experience brought uneasiness about the forthcoming vaccination. I think I’ll be tense, because I was the other times I’ve been vaccinated but anyway I won’t feel comfortable when I get the shot. (5)
Knowledge
Knowledge about the purpose of the vaccination and what it protected against provided motivation for going through with the procedure even if it meant some inconvenience. In addition, it seemed that the information they had received prepared the girls for what to expect. I think I’ll go and see the school nurse and sit down on the sick bed …. Then X [the school nurse] may talk about something and I’ll get my shot. I think it will sting, but then it’ll be over. (9)
Self-image
Statements about personal characteristics showed that self-image can influence expectations. The self-image described in some cases seemed to give confidence to cope: ‘I’m a patient girl’ (21). For others, the self-image seemed to create negative expectations, for example when they thought about themselves as a person who was afraid of needles: ‘I think it’ll hurt quite a lot, and I’ll be quite worried. I’m afraid of getting needles’ (14).
Transforming uneasiness to confidence
Additionally, as an interpretation of the latent content, the theme transforming uneasiness to confidence was formulated. The narratives were interpreted to bear evidence of a growing ability to cope with minor unpleasantness such as vaccinations, however, this ability is sensitive and easily disturbed. Hope to manage pain and anxiety shimmered like the wings of a newly hatched butterfly, beautiful, but fragile, and therefore sensitive to painful and scary experiences.
Discussion
The expectations in the study group varied and expectations that it would turn out fine were found to exist parallel with fear and worries that it was going to hurt. This was understood to illustrate that emotional reactions influence expectations and that the girls expected to be able to suppress the feelings of unpleasantness and transform uneasiness to confidence. During the analysis, an image emerged – that of a newly hatched butterfly, beautiful but fragile. This metaphor was interpreted to illustrate a growing confidence in the ability to cope with minor unpleasantness. This confidence can be understood as programmed or ‘destined’ and as reflecting developmental stages in a pre-programmed maturation process (Fitzgerald and Walker, 2009). It is already known that the younger a child, the more sensitivity there is to pain (Gullone et al., 2001). The inhibitive reactions suppressing pain experiences become stronger with age (Tsao et al., 2013).
For some of the participants, the expected emotional reactions were too strong and they worried about not being able to cope with the situation. The fact that a considerable part of children of this age fear needles (Forsner et al., 2013; Nordyke et al., 2010; Taddio et al., 2012) and that as many as 22% of adults also fear needles (Wright et al., 2009) implicates a need for nursing interventions to decrease these unwanted side effects of vaccination procedures.
Besides giving a picture of expectations prior to the vaccination, the narratives revealed to some extent what these expectations might be based on. Previous experiences, knowledge and images about the selfinfluenced the girls’ expectations. The fact that children are particularly sensitive to negative experiences and that past painful and scary experiences impact expectations has been discussed by Taddio et al. (2009) and is in line with the findings presented by Wright et al. (2009). However, Polkki et al. (1999) found that positive experiences can turn past negative expectations into positive expectations in the future. Therefore, it is important for nurses to act with the intention that each needle-related procedure becomes a positive experience.
Both expectations of pain and anxiety emerged from the narratives. Pain in other parts of the body, for example, in the stomach, can be understood to indicate feelings of stress. The association between pain, anxiety and stress has been demonstrated in previous studies (Tsao et al., 2004). Memories of painful procedures influence children’s reactions to upcoming procedures (von Baeyer et al., 2004), and anxiety additionally influences children’s memories of painful procedures (Rocha et al., 2009). However, not all the girls expected the vaccination to hurt and not all thought that they would be frightened. Rather, they expressed the hope that it would not hurt and that they would not be frightened. The children seemed to try to cheer themselves up, and the narratives revealed self-pep talk as a strategy. This was perhaps a sign of maturity showing that children of this age are beginning to be able to cope with minor unpleasantness. Nevertheless, it is not so simple as to say that all children in this age group should be expected to be able to handle pain related to injections. One factor with great impact on children’s thinking is their imagination both in a positive and in a negative direction (Forsner et al., 2005). Negative fantasies can impact the procedure so that it is experienced as more scary and painful (Forsner et al., 2009). Although the imagination was not manifest in the narratives, it still seems to have influenced the expectations. Furthermore, past experiences (von Baeyer et al., 2004) and developmental neurobiological factors (Fitzgerald and Walker, 2009), as well as catastrophizing, that is, having an exaggerated negative orientation towards actual or anticipated pain, are understood to influence children’s pain experience (Sullivan et al., 2001). The findings in the current study can be interpreted to indicate that developmental issues, in combination with past experiences, should be considered to influence expectations prior to vaccinations.
Methodological considerations
The decision to use short written narratives allowed for description of expectations without influence from an interviewer, which has been interpreted as a risk in face-to-face interviews (Graneheim and Lundman, 2004). The method has been previously used with children of this age (Forsner et al., 2013; Nordyke et al., 2010) and has been found to capture more positive and neutral views of children’s experiences compared with more structured questionnaires (Carney et al., 2003). On the other hand, written narratives do not allow for further follow-up questions, which would have clarified any uncertainties as to the meaning and possibly added information where narratives were short. Additionally, 13 of the 40 invited children did not respond with the requested narrative, and we do not know what they would have added to our findings. Despite these limitations, the narratives demonstrated a range of expectations and also variation regarding the basis for these expectations. Although generalizability cannot be claimed, these findings may contribute to knowledge about what matters to children when faced with medical procedures such as vaccinations.
Conclusion and clinical implications
The conclusion drawn from this study is that girls of this age mostly seem to feel confident about their ability to cope with the vaccination. However, some of the girls considered the injection very unpleasant, which undermined their confidence to cope with the procedure. Previous research has found that most children in this age group do not find needle-related procedures problematic but that some children have problems with anxiety (Forsner et al., 2013; Nordyke et al., 2010). Additionally, although fear of needles is common in childhood, it has been found to decrease in adolescence (Taddio et al., 2012).
Nursing care is not solely about administering the injection required for vaccination, but, as Randall and Hallowell (2012) state, it is a nurse’s duty to act to mitigate children’s experienced negative effects of the healthcare delivered. Clinical nursing practice related to childhood vaccinations ought to include approaches to promote children’s own coping strategies and identify those in need of extra support. Self-assessments to identify children in need of extra support (Nilsson et al., 2014) and distraction techniques such as guided imagery to promote the child’s own coping (Landier and Tse, 2010) may be promising nursing interventions related to school health vaccinations.
Footnotes
Acknowledgements
We would like to thank the participants of the study who generously shared their time and experiences. We would also like to thank the school nurses who helped us in conjunction with the data collection.
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research of this article: Grants from the Ebba Danelius Foundation supported this research project.