The domino effect: adolescent girls’ response to human papillomavirus vaccination

Diana M Bernard, Spring C Cooper Robbins, Kirsten J McCaffery, Caroline M Scott and S Rachel Skinner
Med J Aust 2011; 194 (6): 297-300. || doi: 10.5694/j.1326-5377.2011.tb02978.x
Published online: 21 March 2011


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.

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.

Data collection

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 were conducted among adolescent girls aged 12–16 years during the school year when they were offered the HPV vaccine, with each group comprising girls of similar age (eg, 12–13 years). All parents of focus group participants had received information about the HPV vaccine and had already consented to or declined vaccination. The girls had been given the opportunity to have at least one vaccine dose.

Individual interviews were conducted with parents, who were not necessarily parents of girls who participated in the focus groups. Interviews were also conducted with teachers and vaccination nurses. Focus group and interview prompts were informed by the literature and, subsequently, by data analysis in a dynamic way to ensure all potential themes were explored.

The following topics were explored in relation to HPV and HPV vaccination: attitudes, decision-making processes, knowledge and understanding, experience of vaccination, discussion with family and friends, and any questions and concerns raised by participants. Examples of prompts used included, for adolescents, “Can you tell me about what happened when you went to have the vaccine?”, and for teachers, “How do the students in your school respond to the vaccine program?”


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).

Factors affecting fear

Factors both promoting and mitigating fear were identified; some factors influenced fear in more than one direction (Box 2).


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

  • Diana M Bernard1
  • Spring C Cooper Robbins1
  • Kirsten J McCaffery2
  • Caroline M Scott3
  • S Rachel Skinner1

  • 1 Discipline of Paediatrics and Child Health, University of Sydney at the Children’s Hospital Westmead, Sydney, NSW.
  • 2 Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, NSW.
  • 3 Centre for Population Health, Sydney West Area Health Service, Sydney, NSW.



We thank NSW Health for their cooperation with this study and their invaluable advice and feedback on the results. We acknowledge CSL Ltd, Australia for partial funding of this research, in the form of an unrestricted research grant. We acknowledge the invaluable input of the parents, adolescents, teachers and nurses who participated in this study, and each of the schools that allowed the onsite research to be undertaken.

Competing interests:

Spring Cooper Robbins has received travel grants for meetings organised by CSL. Kirsten McCaffery has received a speaker’s fee from CSL and a consultancy fee from GlaxoSmithKline (GSK). Rachel Skinner has received travel and research support from GSK and CSL to attend conferences to present data, and in the past has received honoraria from GSK and CSL for participating on advisory boards and educational seminars. She has been principal investigator for GSK on clinical trials of their HPV vaccine.

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