How Perceptions of Responsibility and Affective Consequences Influence Parents’ Digital Media Engagement in Relation to Human Papillomavirus Vaccination

Abstract

Individuals are expected to be responsible for their own health and that of their families—and act accordingly. Yet, being in a position of responsibility might be undesirable for individuals either unable or reluctant to comply with the expectations this responsibility entails. In this article, I explore how parents experience the process of engaging responsibly with digital media in relation to the question of human papillomavirus vaccination. The study is based on interviews with eighteen Danish parents, and my findings show that these parents not only understand themselves but also other actors in terms of responsibility, and that being positioned in terms of responsibility can have negative affective consequences. I argue that meeting the expectations of biological citizenship should not necessarily be a goal in relation to complex health topics.

Keywords

biological citizenship health digital media human papillomavirus vaccination qualitative research parents decision-making

Introduction

In Westernized societies, individuals are increasingly understood as responsible for their own health (Rose, 2007; Stage, 2015) and as actively having to make decisions about health. As such, a responsibilization of health has occurred. Responsibilization is understood here as “a technique that turns individuals into subjects that consider themselves as free and responsible for their own actions as well as the respective outcomes” (Biebricher, 2011, p. 471). Rose (2007) presents the notion of the individual as an “active responsible biological citizen” who is “actively shaping his or her life course through acts of choice, activities that extend to the search for health in the face of the fear of illness, and the management of the risks – not the genetic susceptibilities – of disease” (Rose, 2007, p. 154). Active biological citizens are, according to Rose, obligated to inform themselves about illnesses as well as susceptibilities and predispositions (Rose, 2007). Furthermore, individuals as active citizens are expected to act responsibly regarding their own biology (Stage, 2015). The positioning of individuals as responsible can be state-initiated (Ward et al., 2017), and it can also be facilitated by digital media (Erikainen et al., 2019) such as through demonstration of advice through imperative formulations on websites (Lawless et al., 2018).

While health-related responsibilization can be considered empowering for individuals, the focus on the responsibility of the individual can also be argued to “reflect neoliberal discourses around decreasing state accountability” (Erikainen et al., 2019, p. 3). Responsibilization further risks increasing what is expected of individuals without necessarily considering whether individuals are able to comply with these expectations (Erikainen et al., 2019; Lawless et al., 2018). Nevertheless, being positioned as active responsible biological citizens, individuals are discursively expected to engage in their own healthcare (Erikainen et al., 2019).

In this article, I focus on individuals making decisions on a complex health topic, namely, vaccination. In terms of responsibilization, vaccination is not straightforward as it is not given that parents choose to vaccinate. Rather, it is “an individual choice and decision” (Ward et al., 2017, p. 1119), and parents may be judged in terms of responsible parenting depending on the decisions they make (Ward et al., 2017). Decisions on vaccination have been widely explored in qualitative health research focusing on both individuals’ decisions (e.g., Dubé et al., 2016; Majid & Ahmad, 2020; Niccolai et al., 2016; Nordtug, 2021; Rendle & Leskinen, 2017) and policy adoption (Vázquez-Otero et al., 2021). Research has, for instance, focused on which factors can or do contribute to acceptance of vaccines (Lindsay et al., 2021; Niccolai et al., 2016). Lindsay and colleagues found these factors to include beliefs about risk related to human papillomavirus (HPV) and benefits of vaccination, psychosocial and cultural influences, and the role of health care providers (Lindsay et al., 2021). The role of health care providers and specifically their recommendations is also stressed by Niccolai and colleagues (Niccolai et al., 2016). Another area of focus in qualitative health research on vaccines is vaccine hesitancy, including factors that may bolster hesitancy and delays (Majid & Ahmad, 2020; Rendle & Leskinen, 2017). Vaccine hesitance and decisions to delay vaccines are complex processes (Rendle & Leskinen, 2017), and in a review exploring vaccine hesitancy, Majid and Ahmad, for example, identify seven factors which have been found to promote hesitancy. These factors include “previous experiences; ‘natural’ and ‘organic’ living; perceptions of other parents; experiences interacting with health care providers; information sources; challenges, and preferences; distrust in health system players; and mandatory vaccine policies” (Majid & Ahmad, 2020, p. 1771).

In this article, I wish to expand on this research. I suggest that how individuals perceive themselves in terms of responsibility for understanding information about vaccination influences their decision-making process in relation to vaccines. Specifically, I explore how they engage with digital media on the issue. I focus particularly on vaccines against HPV in Denmark, in which there was a fall in vaccination uptake amongst 12-year-old girls following negative media coverage about concern over the safety of the vaccine (Suppli et al., 2018). Mohr and Frederiksen (2020) found that public perspectives on HPV vaccination in Denmark were conflicting. This can complicate making a decision about the HPV vaccine for parents; a decision that might already not be straightforward (Mohr & Frederiksen, 2020). I explore this topic by asking the question:

RQ: How do parents’ perceptions of responsibility influence their digital media engagement in relation to HPV vaccination?

I focus specifically on digital media as the internet is amongst the dominant sources of health information for the Danish population (Kummervold et al., 2008; Tassy et al., 2020).

To answer this question, I first analyze the degree to which the parents in my study perceive themselves and other actors in relation to responsibility for understanding information about HPV vaccination. As such, I do not study the parents’ legal right to decide whether to vaccinate their children. Rather, I focus specifically on how parents engage with digital media in relation to how they perceive themselves and others in terms of moral responsibility. Furthermore, I analyze how being discursively positioned as a responsible individual is experienced by the parents.

In analyzing the parents’ engagement with digital media in relation to the question of HPV vaccination, I rely on Corner’s conceptualization of engagement (Corner, 2011). Corner (2011) describes engagement as a selected kind of attention that involves a higher degree of cognitive focus than merely being exposed to information. In this article, I also include an intensive form of engagement referred to by Corner as involvement which “involves more sustained cognitive and affective work” (Corner, 2011, p. 91). However, this intensive kind of engagement will in this article be referred to as engagement. Corner suggests that the internet offers a great variety of opportunities for engagement and involvement such as reading, viewing, navigating, and interacting (Corner, 2011).

To understand whether the responsibilization is empowering or undesirable for the parents, I analyze the affective consequences of responsibilization. I do this through analyzing the parents’ experiences of being responsible individuals who are expected to engage accordingly. Specifically, I explore this through “communicative content about experienced or attributed affect” (Knudsen & Stage, 2015, p. 9). I thus explore how parents communicate their experiences in the interviews that will be presented in the coming section. In this article, I understand affect as a performative and embodied process (Reestorff & Stage, 2018, p. 317) that manifests in the interviews as descriptions of feelings and embodied states of mind when making a decision about the HPV vaccine. As such, I identify the affective states described by the parents and link them to their experienced perceptions of responsibility for understanding information about vaccination. Thereby, I am able to trace the presence of affective forces (Knudsen & Stage, 2015) and disclose the affective consequences of being positioned as a responsible individual.

Methods

The analyses are based on interviews with eighteen Danish parents of 10- to 13-year-old girls, as the HPV vaccine was primarily offered free of charge to girls from the age of 12 when I conducted the interviews, namely, from January 2018 to June 2019 (SSI.dk, 2019). The parents included in the study were recruited through snowball sampling, in which I was referred to potential participants by my network or by the participants themselves (Halkier, 2008), and through contact with schools, who were willing to post information about my project and my contact information either at the school or on school intranets. I chose these two different kinds of sampling in an attempt to recruit parents of various demographics: schools will often have various parents, and through snowball sampling I was, for instance, able to ask specifically for parents with different demographics than those I had already interviewed. Five of the eighteen parents were recruited as part of an initial pilot study. After conducting the interviews that comprised the pilot study, I conducted a preliminary analysis to find out which parents to mainly focus on in my study. Based on this analysis, I found that it was most fruitful to interview parents who had either not decided on the vaccine or who had recently made the decision; the interviews with these parents were more rewarding, as the parents appeared more able to communicate about their thoughts about the vaccine and their digital media engagement. As a result, I specifically sought these parents to interview. Parents were thus included as interviewees if they had at least one daughter aged 10- to 13-years-old and appeared to be in the process of deciding or close to their decision to vaccinate. During the later interviews, it emerged that four of the interviewed parents had already decided some considerable time previous to the interview to have their daughters vaccinated. However, these parents were included in the analysis as they still provided valuable insights. The interviews lasted between 44 minutes and 1 hour and 59 minutes and were conducted at a place of the parents’ choosing. All parents were made aware of the aim of the study and consented to participate. My data collection was approved by the Institutional Review Board of the University of Southern Denmark, the Research and Innovation Organization (RIO).

I interviewed parents with a variety of educational backgrounds such as short-cycle, further and higher education, vocational training, and basic school education. Furthermore, I interviewed parents who were in the labor market as well as parents who were out the labor market. The parents were white or white-passing¹ and between ages 37 and 52 years old. A clear majority of the parents interviewed are mothers (n = 16/18). The overrepresentation of mothers might create uncertainties regarding the validity of this article’s aim to study “parents” as an overall group (Brinkmann & Kvale, 2018). However, making decisions about HPV vaccination is often considered to be the responsibility of mothers (Albert, 2019; Grandahl et al., 2017; Kemberling et al., 2011; Lindsay et al., 2021). Mothers primarily being in charge of making the decisions about HPV vaccination is also found to be the case in a report conducted by the Danish Health Authority (SST.dk, 2017). To meet anonymity concerns, the overrepresentation of mothers has resulted in parents only being referred to in the gender-neutral term “parent.”

I conducted the interviews by asking the parents to make messy maps about the HPV vaccination situation and by use of semi-structured interview questions (Kvale & Brinkmann, 2015; Nordtug, 2020). Messy map interviews is an interview tool inspired by Clarke’s situational maps, and it is a technique in which interviewees map relevant elements in a situation (Clarke et al., 2018; Nordtug, 2020). The messy maps were created by giving the parents pieces of paper and a pen and asking them to map elements based on open-ended questions such as “If I say HPV vaccination, could you write down everything that somehow matters in relation to that?”. I transcribed the interviews and coded them in the computer-assisted qualitative data analysis software NVivo. In my analysis, I am inspired by a Situational Analysis approach (Clarke et al., 2018). In NVivo, I first coded all interviews for elements that were present, and I then ran queries on the relations between some of the elements all or most parents had mapped, mimicking Clarke’s relational maps (Clarke et al., 2018). Relational maps are created to specify the relations among various elements, and these maps can help analysists decide which stories to pursue analytically (Clarke et al., 2018). Based on my relational maps, I found the relations between the element “Being a responsible parent” and different elements related to digital media to be profound, as all parents to a certain extent discussed being a responsible parent in relation to digital media engagement in my interviews. Furthermore, affective consequences of being a responsible parent were also profound in the material. For the purpose of this article, I thus subsequently coded all eighteen transcribed interviews in NVivo, and to answer the research question of the article, I coded the interviews according to (1) the parents’ engagement, (2) perceived responsibility, and (3) affective consequences. Using these codes, I am able to understand the empirical material in terms of the theoretical notions of engagement, responsibilization, and affect.

My analysis shows that the way in which Danish parents perceive themselves in terms of responsibility is related to how they perceive other actors in terms of responsibility. Whereas some parents perceive themselves as primarily responsible for understanding information available about HPV vaccination, other parents consider either individual health professionals, the media, or institutional health authorities to be primarily responsible. I have categorized all parents according to whom they appear to perceive as having the primary responsibility for understanding information about HPV vaccination. However, as I did not ask the parents directly about this, they were not able to explicitly position themselves. The lines between where the responsibility is positioned are not strict, and whereas one individual health professional might by some parents be seen as a representative for the health authorities as a whole, other parents might, for instance, consider a specific general practitioner (GP) to know more about their specific child and situation than the institutional health authorities. How parents are positioned is based on analyses of the interviews in full, and I have placed the parents in the category that resonated most within the individual interview.

Analysis: Experiences of Engaging in a Responsible Way

In the following analysis, I elaborate on how the parents perceive themselves and the aforementioned other actors in terms of responsibility for understanding information about HPV vaccination and how the perceptions are related to the parents’ engagement with digital media in relation to the question of vaccination. Furthermore, I analyze the parents’ experiences in terms of affective consequences.

Parents as Primarily Responsible

Some parents perceive themselves to be primarily responsible for understanding information about HPV vaccination. According to these parents, you should “bother to” learn about the vaccine. Parents perceive themselves and sometimes other parents as having the responsibility to familiarize themselves with information about the vaccine. Following this logic, parents should try to understand the topic, or gather ample information and sort through it in order to make an informed decision. The parents might consult other actors such as health professionals, friends, or websites, but according to these parents, it is ultimately their own responsibility to find out what information to trust.

Parents who perceived themselves as responsible for understanding information about vaccination suggest that they themselves (and other parents as well) should do a certain amount of work to become informed about the vaccine. One parent, for instance, says that:

[…] you can’t know everything, but if something is important to you, 2019 is here to tell you that it’s a choice if you don’t know anything about it at the end of the day, it’s so easy to find someone who knows something that you can find out. You may not be able to figure it out in five minutes, but you can learn things, right? I mean.

This parent thus suggests that not knowing about issues such as vaccination should result in a learning process. Furthermore, with reference to a popular board game, the parent also points to an obligation to find out how to understand information about the vaccine:

[…] but if it’s easily revealed that there are large grey areas in my “knowledge cheese”, I wouldn’t be able to look myself in the eye if I didn’t do something to fill out those gaps. And I’ll also say, fuck it, you should too.

In the above quote, the parent once again suggests that it is important to learn and puts that obligation upon other parents as well. In the interview with another parent, a similar image of the parent as responsible for understanding information about vaccination occurs:

[…] with regard to this with the HPV vaccine, well, then of course I looked up the side effects associated with it and kept up with the debate that's been going on, but I've also read the conclusions of the reports that have been done on it.

As shown in the quote, this parent has done a great deal of work to become informed about the vaccine. How parents such as the two introduced above perceive themselves is thus consistent with the concept of biological citizenship as they do conduct a certain amount of work to become familiar with how to maximize their children’s health (Rose, 2007).

Some of the parents who perceive the responsibility as being their own point to a lack of trust in other actors who could have provided information about the vaccine. Parents may feel that the news media has not provided a clear answer about the vaccine due to interests besides providing information, as suggested by one of the parents: “Because researchers need their research to be seen, and the newspapers need good headlines that can give them some clicks […].” Furthermore, parents might not trust health authorities or health professionals’ intentions, and they typically do not trust the pharmaceutical industry, as suggested, for instance, by another parent: “But the argument about the pharmaceutical industry buying their way in, well, that affects me too.”

Because of this potentially non-present trust in other actors, the parents then take the responsibility upon themselves. This might require the parents to develop a self-trust to be able to handle this responsibility (Ward et al., 2017).

The parents who perceive themselves as primarily responsible for understanding information about HPV vaccination appear to engage with digital media in relation to the vaccine in two overall ways. The two kinds of engagement are interpersonal communication and using digital media as information sources.

First, regarding interpersonal communication, some parents point to engaging in dialogue with others on social media by asking about statements or articles. One parent, for instance, claims to have contacted others through social media when having read a piece of information on HPV vaccination: “[…] then just write, hey, where did you get that from? Or would you mind sending that article? Or could you, something or other, you know? And then people do if they have it.” Thereby, even though it is possible that parents learn something that differs from the acknowledged public knowledge about the vaccine, parents can potentially be educated by or learn something from those they are communicating with.

Second, in using digital media as information sources, many parents have seen or heard news, discussions and information through various sources, which may prompt them to search further information. Some of the parents engage by actively gathering information through reading different websites on the topic. As one parent says, “it is not enough to just get things from one angle.” It differs whether the parents have specific websites they consult, or if they point to one or more websites that they find particularly trustworthy. One parent, for instance, prefers certain websites such as the Danish health portal “Sundhed.dk” [Health.dk], which is a digital entrance to the Danish healthcare system owned by the state, the municipalities, and the regions (Sundhed.dk, 2018):

Well, Sundhed.dk, I guess that’s really my main point of access if I need to find out something or other, where there’s often, there’s a great description of things, and there’s quite often links to other pages, and if you want to be a bit nerdy, well, then there’s also a portal for health professionals where there’s a bit more information.

Furthermore, the parents might dismiss specific information, such as headlines on the social media site Facebook, “doomsday articles,” or information that might challenge their decision to vaccinate. The parents point to a need to be source critical, sorting through information using common sense, and also trusting their gut feeling when coming across information.

Individual Health Professionals as Primarily Responsible

Other parents perceive individual health professionals to have the primary responsibility for understanding information about HPV vaccination. When parents perceive individual health professionals to be primarily responsible, the parents also perceive health professionals to be the best and potentially only reliable source of information about HPV vaccination by virtue of their professional expertise.

One of the parents who perceive individual health professionals as primarily responsible says that they themselves do not know enough about vaccines, which is why they have instead chosen to talk to a health professional:

Then of course I’ve talked to a doctor about it, I’ve talked with a doctor’s secretary about it, I mean, gotten some other, some professional inputs, and then I think, I mean, you must choose to trust that the people who work with it [HPV vaccination] and have knowledge about it, they might be the ones who know best.

This parent thus appears to rely on the doctor to have the knowledge about the vaccine that the parent does not have. As such, if the parents do not have the medical proficiency themselves, some say they will not be in a position to understand the information as well as health professionals. Relying on individual health professionals to understand knowledge about HPV vaccination also occurs in the interview with another parent:

And then I think, I would let, I would personally let him [the GP] assess what is best for the child. I wouldn’t make that judgement myself. And that’s because I think, even though I am a parent, I am, it’s not, it’s not my area of expertise, it’s not what I know the most about. I know what it is to be a [parent], but I am not a doctor or a nurse. And that’s why I think that the trust in that there are some professional experts who know about this, I actually have that trust.

In letting a GP decide what is best for the child, the responsibility for finding out what is considered to be the best decision is entrusted to the health professional. Individual health professionals are by some parents presented as authority figures who are close to them that can confirm or reject information parents have found elsewhere, or who can, as mentioned, make the decision about the vaccine. This can be because the GP knows the child in question and is therefore most suited to answer questions about that particular child. Some parents believe that what health professionals say will be based on research or the newest knowledge available and thus have a responsibility to understand the knowledge they present. These parents do not necessarily challenge what Rose (2007) presents as “the paternalistic power that doctors exercised over their patients and their lives” (Rose, 2007, p. 10). Rather, the parents welcome the exercising of this power and consider individual health professionals to be the safest actors to trust to understand and communicate information about the vaccine. As such, when parents trust individual health professionals, the parents can allow the individual health professionals to be in a position of responsibility. Thereby, in terms of biological citizenship the parents can partially distance themselves from the position of responsibility they are discursively in.

The parents who perceive individual health professionals as being primarily responsible mainly engage through using digital media as information sources. Many of the parents have seen information or heard stories about HPV vaccination. Whereas some parents might search information on the internet about the vaccine, others consider the amount of information and headlines available through digital media to be too overwhelming, which is why they choose not to actively search for information on the vaccine. This was, for instance, the case for one of the parents:

Well, then I’ve just written ‘HPV vaccine’, and then what appears. And a lot appears. Articles and medical science and all sorts of things. And I actually couldn’t really face looking through everything. So, I chose to talk to the doctor instead and thought that’s who’s closest.

Digital media are not necessarily understood to be trustworthy as an isolated information source. The parents who do mention searching for information through digital media point to needing to be critical of what they read on the internet or needing to validate information from internet sources with a GP. Some parents, however, are so unsure of the validity of information available through digital media that they neither can nor will allow themselves to be educated by the information found. Rather, the opportunity to be in a position of responsibility, as the biological citizen is in its core (Rose, 2007), appears to be undesirable.

The Media as Primarily Responsible

The media, understood mainly by parents as news media, can also be perceived by parents to be primarily responsible for understanding information on HPV vaccination. In this case, the parents trust the Danish news media to find the people who have the right information and present that information to news consumers. This information could, for instance, originate from the Danish Health Authority or a health professional.

When talking about what makes information about HPV vaccination trustworthy, one of the parents who rely on the news media to understand and present information about HPV vaccination, for instance, says:

It’s a doctor, a professionally trained doctor, who turns up in connection with, I mean, it’s not in connection with an interview in, I mean, in connection with a news broadcast, for instance, then I would think that it’s a reliable doctor, a reliable source, the news broadcast has found.

The parent thus expects the media to find not just a health professional, but a reliable health professional. The news media are thereby placed in a position of responsibility for communicating correct understandings about the vaccine. As the reports about HPV vaccination have gotten more positive, the parents who perceive the media to be responsible have also gained faith in the vaccine. This can, for instance, be seen in the interview with another parent, who says that:

[…] you have to remember all the good stories too instead of just listening for the bad ones. And I think that I’ve mainly heard good things about it [HPV vaccination] now, so I think we’re headed towards deciding that she is going to get it [the vaccine] […] I think we’re hearing more positive things about it now than we did a few years ago with side effects and all that. That they’ve found out that it’s, that it’s good enough.

The abundance of positive accounts about the vaccine in the media thus appears to have an affirmative effect on parents like the above-quoted. In another case, a parent had decided on the vaccine without having actively consulted the internet or having consulted a GP, but the parent frequently mentioned having heard health professionals and representatives for the Danish Health Authority make statements in news television. What these actors said on the news was then what the parent chose to follow.

These parents might also engage through using digital media as information sources. Some have read and listened to information in the media, though it differs whether this includes both news media and social media. As shown above, one of the parents talks about trusting the dominant stories in the media, and also says that they only now started to listen to the stories about HPV vaccination: “[…] it’s not until now, when you get children of that age yourself, that you start to listen carefully, I think.”

Interestingly, the press and journalists are, by other parents than the ones perceiving the media to be primarily responsible, frequently mentioned as actors that cannot be trusted to understand information about HPV vaccination. As one parent says, “they are journalists, and what do they know, right?” thus questioning journalists’ knowledge about health and vaccines. As such, other parents perceive that the media are not living up to their responsibility to understand information about the vaccine, why it can be undesirable to be educated by the media.

Institutional Health Authorities as Primarily Responsible

Parents who perceive institutional health authorities to have the primary responsibility for understanding information about HPV vaccination typically have great confidence in actors such as the Danish Health Authority which can be understood as representing broad public knowledge on a health topic. As such, according to these parents, the Danish Health Authority is obligated to provide correct information to the public. Therefore, when the Danish Health Authority recommends something, that recommendation should be followed. This is, for instance, evident in the interview with one of the parents. This parent believes that parents do not need to go into thorough considerations about the vaccine because it is recommended by the Danish Health Authority:

[…] Besides, it’s recommended, so I think, how should I put it? Well, I don’t know what to call it, but our public institution has somehow assessed that this [vaccination against HPV] is an advantage. […] So, I think that’s fine.

According to this parent, the Danish Health Authority knows best, and the vaccine will only be offered if the vaccine is under control. Even if the quality of the research on the vaccine is questioned, the health authorities are still an actor parents such as the above-quoted can choose to trust if they experience being unable to find and understand the information themselves. This is also evident in the interview with another parent:

I can’t go deeply into HPV vaccines, I can’t. Well, I can scratch and look, scratch the surface, look at, what do they say, what do they say, okay, then you have to make a decision, right? And I, yes, and I really count on, okay, that if our healthcare system recommends it, okay, so then it probably isn’t, then it’s not wide of the mark, I think.

Some of these parents also engage through using digital media as information sources. Generally, as the parents trust the recommendations made by actors such as the Danish Health Authority, the parents’ engagement will typically be simply to check up on the recommendations put forward by the Danish Health Authority. The parents will not necessarily try to understand HPV vaccination further. The parents might also consult the Danish Cancer Society’s website or a governmental HPV campaign Facebook site to get information about the vaccine. The parents might have heard about the vaccine elsewhere, but do not necessarily think this information is trustworthy. However, some parents might not actually engage with digital media as they will either not get around to it, or they might not believe it is necessary to gather information if one just trusts the Danish Health Authority.

Affective Consequences of Being Positioned as a Responsible Individual

The above analyses show that parents do not necessarily only perceive themselves in terms of responsibility for understanding information about HPV vaccination. Thus, they do not necessarily live up to the expectations of biological citizenship. However, in the following I argue that being discursively positioned as a responsible individual may have affective consequences for parents. Consequently, in the following analysis, I suggest some of the affective consequences the responsibilization of health entails for the parents. Through this analysis, I will be able to discuss whether the responsibilization of health is either empowering or undesirable for the parents.

First, one parent points to disagreements between two parents regarding the decision to vaccinate their child, pointing to interpersonal affective consequences of responsibilization. In this case, the two parents of the child disagree on whether the child should be vaccinated. This was, for instance, the case for one of the parents: “I’m actually, I’m divorced from their [other parent]. And we actually quite disagree on this vaccine.” The responsibilization thus entails that “the responsible decision” for a particular child is not a given, and the parents may disagree due to different understandings of responsible parenting.

Second, the amount of information can make parents feel overwhelmed with all the information they can possibly read through. The amount and variety of information available on the internet can make parents unsure of what and whom to trust, which then leads to the parents having to deal with this mistrust. The parents might choose to trust certain information sources, but the parents might not feel they have the time to sort through all the information available on the vaccine. Furthermore, they may not trust themselves to reach the right decision. Consequently, the parents may decide to trust certain but limited information sources. One parent lacks help with trying to understand the information, and the many information sources can be confusing, as another parent points to in the interview: “Well, I mean, you can sort of get more confused than enlightened.”

Third, the responsibilization may induce doubt. It can be difficult to make a decision regardless of whether parents search for considerable or small amounts of information about the vaccine. Because of the health risks that have been mentioned in the media, parents may experience doubt as to whether they made the right decision, wishing away the responsibility for making the decision: “I wish I didn’t have to make a decision about precisely this vaccine.” Similarly, had it not been for the media, one parent imagines being able to live in blissful ignorance:

Well, I mean, I think it brings forward some opportunities, that you have the opportunity to search on the internet. But I think, sometimes it can have the other effect, I mean. Because I think if it were my parents who had to make that decision at that time, well, then they didn’t have the opportunity to search on the internet as we do today. So, it’s very likely that they wouldn’t have gotten all those scare stories. I mean, then you might live in blissful ignorance about what might happen. But I think I can use the internet to get some information about it.

Having to be a responsible individual can thus negatively affect parents and appear as an undesirable burden.

Fourth, the responsibilization may make parents uncomfortable, as the variety of information can make parents uncomfortable about making a decision:

The risk of not getting vaccinated is equivalent, it’s a nuanced picture that there wasn’t room for, that was what made my alarms go off at first, that the nuance in just saying yes or no was, or, there are no nuances in just saying yes or no, and I didn’t hear any nuanced views. And I get that, I mean, I actually still get it, when I meet someone who is nervous about getting their children vaccinated, I was nervous about that too.

Parents may also experience an ambivalent relationship to the information in the media:

Then it’s both good and bad that you get as informed as you do with the media we have, or the access to media we have today. Sometimes it might have been nice to be spared from it. ((Laughs)). But then again, you can’t be upset that you’re getting information. But sometimes you also hear something you don’t want to hear.

Hearing something you do not want to hear thus points to another kind of discomfort.

Conversely, some of the parents do not necessarily experience any problems with the amount of information available. The parents might think it is nice to be able to get information about the vaccine through various sources and have no issues when it comes to sorting through the information. Yet other parents have not experienced negative information about HPV vaccination on social media and have not been influenced by others’ negative experiences.

Discussion

The turn towards responsibilization transfers the responsibility for understanding health to individuals, thereby potentially empowering these individuals (Rose, 2007). Paradoxically, however, the empirical findings show that the parents who do not perceive themselves as primarily responsible for understanding information about HPV vaccination partially distance themselves from this responsibility. The analysis shows that though some parents perceive themselves as primarily responsible for understanding information about the vaccine, the parents also perceive other actors as being responsible. These other actors are also by some parents perceived as primarily responsible, pointing to a tendency amongst some parents who do not expect to bear the responsibility alone. This is the case even though following the vaccine advice of actors such as the state or health professionals is inconsistent with the turn towards responsibilization, as, arguably, merely following the authorities’ recommendations is not consistent with the responsibilities of the biological citizen (Rose, 2007; Stage, 2015; Ward et al., 2017). Nevertheless, parents do not necessarily feel obliged to find information about HPV vaccination themselves with no help from other actors, but perceive other actors as having responsibility for this as well. Also, if parents do not trust their own ability to have this responsibility, following the advice of a trusted actor may be experienced as more responsible behavior. Thus, though the health promotion programs available might be provided to educate decision-makers (Rose, 2007), the parents might choose to trust the information provided to them without feeling obligated or able to understand the information completely.

The analysis suggests that being discursively positioned as responsible can be experienced as a burden, and the parents may not wish to be involved further in health care in relation to HPV vaccination. Acting responsibly in this situation may thus only concern getting information through access and interaction. A consequence of this could be that parents cannot be considered as empowered in relation to HPV vaccination. However, letting those in knowledge positions determine their decision may help lift a burden from parents or not put it upon them in the first place. Though some parents will already be in knowledge positions, for example, through their job as a health professional, others regard themselves as unable to become as knowledgeable as actors such as individual health professionals and institutional health authorities. Thus, to some extent, parents may inform themselves about susceptibilities of becoming ill (Rose, 2007), but not being or feeling competent within the field of vaccines may be a reason not to want to engage further with digital media. In talking about who should assess whether a child should get the vaccine, one parent points to leaving that up to a GP on the basis that the GP will know more about the topic. Positioning other actors as primarily responsible may be linked to a lack of self-trust (Ward et al., 2017), or not having the level of self-trust needed to be comfortable with the responsibility. From a theoretical point of view, this stance may make it appear as though the parents are not taking upon themselves the responsibility to understand their children’s susceptibilities, thereby risking being understood—in terms of responsibility—as morally transgressing (Ward et al., 2017). However, as the analysis of the affective consequences shows, the responsibility that can be required from individuals regarding their health (Rose, 2007; Stage, 2015) may be experienced as overwhelming and uncomfortable. Rather than empowering the parents, the responsibilization and the expected engagement may thus appear as undesirable as it puts expectations upon the parents that they feel unable to comply with. Being responsible for making a decision about HPV vaccination does not only entail choosing the vaccine or not; parents may experience being accountable for the consequences of vaccinating, and thus being able to calculate how it will affect their child to get the vaccine (Raffoul, 2010). This thus points back to the critique of responsibilization as a discourse working to decrease state accountability (Erikainen et al., 2019), a decrease that might be considered undesirable for the individual parent.

Nevertheless, the affective work of being responsible may be considered necessary should the parents distrust other actors with the responsibility. Parents’ lack of trust in other actors may bring about a need to develop trust in themselves to be able to understand complex information (Ward et al., 2017). Trust in other actors can thus have consequences for how the parents perceive themselves and others in terms of responsibility. When societal discourse positions individuals in terms of responsibility but the responsibility is not accompanied by self-trust, the responsibilization is not empowering. Rather, the responsibilization appears undesirable as the individuals are negatively affected by being discursively positioned as responsible individuals.

This study has limitations. First, as presented in the section on the empirical work, a clear majority of the parents are mothers. Further research could explore further why the responsibility for making decisions about vaccination is often considered to be that of mothers as well as go into depth with fathers’ perspectives on this. Historically, fathers have taken less responsibility for their children (Lamb et al., 1987). However, paternal involvement develops between generations, and paternal engagement in children appears to generally predict positive outcomes (Sarkadi et al., 2008). Due to this, explorations of why certain areas of childcare, including responsibility for certain decisions is dominated by mothers, can help to understand underlying aspects of what assist in and stand in the way of fathers’ engagement and paternal responsibility for children. Second, the results of the study may not be transferable to certain other contexts (Tracy, 2010). This is due to the study, including recruiting and interviewing, being conducted in Danish. Though Danish is the official language in Denmark, this may have excluded non–Danish-speaking minorities from participating in the study. Unfortunately, for linguistic reasons, Danish health research often exclude ethnic minorities, resulting in a gap in knowledge about these groups (Zeraiq et al., 2015). Presumably, issues specific to different minority groups may affect minority parents’ perceptions of responsibility and digital media engagement. These are issues such as lack of language skills in the Danish language and a potential lack of confidence in the possibility of receiving help from the Danish system and society (Zeraiq et al., 2015). Exploring minority perceptions and engagement can help to understand minorities’ vaccination practices and possible acceptance, something which is continuously important in societies that increasingly use vaccination as a preventive measure in society.

Conclusion

In this article, I have argued that how Danish parents perceive themselves in terms of responsibility for understanding information about vaccination and how they are affected by being in a position of responsibility influences how they engage with digital media on the topic of HPV vaccination. Thereby, I add to the qualitative health research focusing on individuals’ decisions on vaccines.

Being in a position of responsibility as an individual might for some be considered empowering. However, as I show in this article, the responsibilization of health may be undesirable for the individual parent making a decision about HPV vaccination or similar complex health topics. This is the case as parents may be unable or reluctant to comply with the expectations associated with this responsibilization. The process of understanding information about HPV vaccination and being able to calculate the consequences of vaccinating can affect parents negatively and may be experienced as uncomfortable and overwhelming, induce doubts, or cause disagreements. Due to this, parents may want to distribute the responsibility for understanding information about the vaccine to other actors.

In this article, actors perceived by parents to be in positions of responsibility, aside from the parents themselves, are individual health professionals, institutional health authorities, and the media. One might question whether the parents measure up to the ideal of the responsible individual when they distribute this responsibility. However, other actors can—based on their knowledge position alone—be considered to be in a better position for understanding this information. Expecting parents to take on the responsibility for understanding this information is not necessarily a meaningful or potentially desirable goal in its own right when it comes to making decisions about complex health topics such as vaccination. In a Western country like Denmark, individuals are expected to be responsible for their own health (Rose, 2007), and parents not taking the responsibility upon themselves alone is not considered to be in alignment with the concept of responsibilization. However, being in a position of responsibility might not be empowering, especially if parents do not trust themselves to comply with the expectations that stem from this responsibility. Rather, when parents trust other actors, the responsibility for understanding information about HPV vaccination may be distributed to these actors, thereby lightening a potentially undesirable burden for the parents. This can have consequences for our understanding of biological citizenship, as adapting to the expectations of the biological citizen may lead parents to be negatively affected by the imposed responsibility. This entails that biological citizenship is not necessarily empowering, and that we should take a critical stance towards understandings of responsibility and empowerment in relation to various complex health decisions such as those concerning vaccination.

Supplemental Material

sj-pdf-1-qhr-10.1177_10497323211065023 – Supplemental Material for How Perceptions of Responsibility and Affective Consequences Influence Parents’ Digital Media Engagement in Relation to Human Papillomavirus Vaccination

Supplemental Material, sj-pdf-1-qhr-10.1177_10497323211065023 for How Perceptions of Responsibility and Affective Consequences Influence Parents’ Digital Media Engagement in Relation to Human Papillomavirus Vaccination by Maja Nordtug in Qualitative Health Research

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval Statement

The project is approved by the Institutional Review Board of the University of Southern Denmark, the Research and Innovation Organization (RIO).

Participant Consent

All interviewees consented to participate in the study.

ORCID iD

Maja Nordtug

Supplemental Material

Supplemental material for this article is available online.

Note

References

Albert

(2019). Beyond the responsibility binary: Analysing maternal responsibility in the human papillomavirus vaccination decision. Sociology of Health & Illness, 41(6), 1088–1103. https://doi.org/10.1111/1467-9566.12887

Biebricher

(2011). (Ir-)Responsibilization, genetics and neuroscience. European Journal of Social Theory, 14(4), 469–488. https://doi.org/10.1177/1368431011417933

Brinkmann

Kvale

(2018). Doing interviews (2nd ed.). SAGE Publication Ltd. https://doi.org/10.4135/9781529716665

Clarke

A. E.

Friese

Washburn

R. S.

(2018). Situational analysis: Grounded theory after the interpretive turn (2nd ed.). SAGE.

Corner

(2011). Theorising media: Power, form and subjectivity. Manchester University Press. http://ebookcentral.proquest.com/lib/sdub/detail.action?docID=1069715

Dubé

Vivion

Sauvageau

Gagneur

Gagnon

Guay

(2016). “Nature does things well, why should we interfere?”: Vaccine hesitancy among mothers. Qualitative Health Research, 26(3), 411–425. https://doi.org/10.1177/1049732315573207

Erikainen

Pickersgill

Cunningham-Burley

Chan

(2019). Patienthood and participation in the digital era. Digital Health, 5, 2055207619845546. https://doi.org/10.1177/2055207619845546.

Grandahl

Tydén

Westerling

Nevéus

Rosenblad

Hedin

Oscarsson

(2017). To consent or decline HPV vaccination: A pilot study at the start of the national school-based vaccination program in Sweden [Article]. Journal of School Health, 87(1), 62–70. https://doi.org/10.1111/josh.12470

Halkier

(2008). Fokusgrupper [focus groups] (2nd ed.). Samfundslitteratur.

10.

Kemberling

Hagan

Leston

Kitka

Provost

Hennessy

(2011). Alaska native adolescent views on cervical cancer, the human papillomavirus (HPV), genital warts and the quadrivalent HPV vaccine. International Journal of Circumpolar Health, 70(3), 245–253. https://doi.org/10.3402/ijch.v70i3.17829

11.

Knudsen

B. T.

Stage

(2015). Affective methodologies: Developing cultural research strategies for the study of affect. Palgrave Macmillan UK. https://link.springer.com/book/10.1057/9781137483195.

12.

Kummervold

P. E.

Chronaki

C. E.

Lausen

Prokosch

H.-U.

Rasmussen

Santana

Staniszewski

Wangberg

S. C.

(2008). eHealth trends in europe 2005-2007: A population-based survey. Journal of Medical Internet Research, 10(4), e42. https://doi.org/10.2196/jmir.1023

13.

Kvale

Brinkmann

(2015). Interview: Det kvalitative forskningsinterview som håndværk [interview: The qualitative research interview as a craft (3rd ed.). Hans Reitzels Forlag. https://hansreitzel.dk/products/interview-bog-15828-9788741263779.

14.

Lamb

M. E.

Pleck

J. H.

Charnov

E. L.

Levine

J. A.

(1987). A biosocial perspective on paternal behvaiour and involvement. In Lancaster

J. B.

Altman

Rossi

A. S.

Sherrod

L. R.

(Eds.), Parenting across the life span (pp. 111–142). Aldine de Gruyter.

15.

Lawless

Augoustinos

LeCouteur

(2018). “Your brain matters”: Issues of risk and responsibility in online dementia prevention information. Qualitative Health Research, 28(10), 1539–1551. https://doi.org/10.1177/1049732317732962

16.

Lindsay

A. C.

Valdez

M. J.

Delgado

Restrepo

Guzmán

Y. M.

Granberry

(2021). Acceptance of the HPV vaccine in a multiethnic sample of latinx mothers. Qualitative Health Research, 31(3), 472–483. https://doi.org/10.1177/1049732320980697

17.

Majid

Ahmad

(2020). The factors that promote vaccine hesitancy, rejection, or delay in parents. Qualitative Health Research, 30(11), 1762–1776. https://doi.org/10.1177/1049732320933863

18.

Mohr

Frederiksen

(2020). A constructed reality? a fairclough-inspired critical discourse analysis of the danish hpv controversy. Qualitative Health Research, 30(7), 1045–1057. https://doi.org/10.1177/1049732320909098

19.

Niccolai

L. M.

Hansen

C. E.

Credle

Shapiro

E. D.

(2016). Parents’ recall and reflections on experiences related to hpv vaccination for their children. Qualitative Health Research, 26(6), 842–850. https://doi.org/10.1177/1049732315575712

20.

Nordtug

(2020). Using messy map interviews to describe and analyse elements pertinent to interviewees. Qualitative Research. https://doi.org/10.1177/1468794120979931

21.

Nordtug

(2021). Who knows best? Health risks and digital media engagement in discourses relating to human papillomavirus vaccination. Sociology of Health & Illness. 43(5), 1191–1205. https://doi.org/https://doi.org/10.1111/1467-9566.13284

22.

Raffoul

(2010). The origins of responsibility. Indiana University Press.

23.

Reestorff

C. M.

Stage

(2018). Medier og affektteori [Media and affect theory]. In Lauridsen

P. S.

Svendsen

(Eds.), Medieteori [Media theory] (pp. 314–331). Samfundslitteratur.

24.

Rendle

K. A.

Leskinen

E. A.

(2017). Timing is everything: Exploring parental decisions to delay HPV vaccination. Qualitative Health Research, 27(9), 1380–1390. https://doi.org/10.1177/1049732316664499

25.

Rose

(2007). The politics of life itself: Biomedicine, power, and subjectivity in the twenty-first century. Princeton University Press. http://ebookcentral.proquest.com/lib/sdub/detail.action?docID=483582

26.

Sarkadi

Kristiansson

Oberklaid

Bremberg

(2008). Fathers’ involvement and children’s developmental outcomes: A systematic review of longitudinal studies. Acta Paediatrica, 97(2), 153–158. https://doi.org/10.1111/j.1651-2227.2007.00572.x

27.

SSI.dk . (2019, 30 August 2019). Vaccination mod Human Papilloma Virus (HPV) [Vaccination against human papillomavirus (HPV)]. Statens Serum Institut. https://www.ssi.dk/hpv

28.

SST.dk . (2017, 10-05-2017). Informations-indsats skal- øge tilslutning til HPV-vaccination [Information campaign is going to increase the support of HPV vaccination]. https://www.sst.dk/da/nyheder/2017/informationsindsats-skal-oege-tilslutning-til-hpv-vaccination

29.

Stage

(2015). Sygdom på sociale medier [Illness on social media]. K&K–Kultur og Klasse, 43(120), 103–124. https://doi.org/10.7146/kok.v43i120.22973

30.

Sundhed, dk . (Eds.). (2018). Du behøver ikke ha’ det hele i hovedet [You don't need to have it all in your head]. København Ø: Sundhed.dk.

31.

Suppli

C. H.

Hansen

N. D.

Rasmussen

Valentiner-Branth

Krause

T. G.

Mølbak

(2018). Decline in HPV-vaccination uptake in Denmark–the association between HPV-related media coverage and HPV-vaccination. BMC Public Health, 18(1), 1360. https://doi.org/10.1186/s12889-018-6268-x

32.

Tassy

Nielsen

M. B.

Jakobsen

D. T.

(2020). It-anvendelse i befolkningen–2019 [IT use in the population–2019]. D. Statistik. https://www.dst.dk/Site/Dst/Udgivelser/GetPubFile.aspx?id=29449&sid=itbef2019

33.

Tracy

S. J.

(2010). Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qualitative Inquiry, 16(10), 837–851. https://doi.org/10.1177/1077800410383121

34.

Vázquez-Otero

Daley

E. M.

Vamos

C. A.

Romero-Daza

Beckstead

Martinez Tyson

(2021). The intersection of problems, policy, and politics: The adoption of an HPV vaccine school-entry requirement in Puerto Rico. Qualitative Health Research, 31(5), 859–870. https://doi.org/10.1177/1049732321991507

35.

Ward

P. R.

Attwell

Meyer

S. B.

Rokkas

Leask

(2017). Risk, responsibility and negative responses: A qualitative study of parental trust in childhood vaccinations. Journal of Risk Research, 21(9), 1117–1130. https://doi.org/10.1080/13669877.2017.1391318

36.

Zeraiq

Nielsen

Sodemann

(2015). Attitudes towards human papillomavirus vaccination among Arab ethnic minority in Denmark: A qualitative study. Scandinavian Journal of Public Health, 43(4), 408–414. https://doi.org/10.1177/1403494815569105

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