Schools-based vaccination sessions
Young people’s independent and autonomous participation within the HPV vaccination programme is influenced by the environment (usually the school setting) in which it is delivered. Young people’s movements and behaviours are controlled and regulated in schools, by the timetable, curriculum, and policies enforced by school staff.
Researcher observations during vaccination sessions highlighted a clear dichotomy between the young women and adults present (school staff and immunisation nurses). To maintain an orderly system, school staff frequently used their authority to control behaviours where young women were excitable and vocally expressed worries about receiving the vaccine. These anxieties related to the size of the needle and anticipated pain from receiving the HPV vaccine. Despite often protesting verbally, young women were mostly co-operative with instructions given by adults during the vaccination session. Where parental consent, either through paper-based consent forms or verbally, had been obtained, it was rare for young women to exercise autonomy and refuse the vaccination during the session.
Despite the legal framework and local policy supporting adolescent self-consent, the immunisation team appeared more comfortable in retaining parents as the responsible party for consent provision. This was reflected in their interactions with students: ‘The trouble is, I need to speak to them [the parents]’ [immunisation nurse, fieldwork, mainstream school 1]; ‘Yes, you’re quite right, she [student’s mother] does want you to have the vaccine’ [immunisation nurse, fieldwork, mainstream school 10]. Young women were complicit with this and appeared to prefer or expect their parents to be responsible for providing consent. This resulted in young women frequently deferring power to their parents, or other adults, to influence whether they received the vaccine or not: ‘If my mum picks up [the phone], I’m having the jab’ [student, field work, mainstream school 1].
The constraints routinely applied against young people exercising choice in a school setting may lead some young women to avoid vaccination by simply not attending school on the day of session. During interviews, some parents mentioned their daughters were absent for vaccination sessions. A few adult participants suggested it may be intentional, but the extent to which this happens remains unclear:
‘I bet a lot of children don’t even turn up [to school], if they know it’s [the vaccination session] happening on Friday’ [Mother 1, community group 2]
‘You’re always going to have a very small number, thankfully, that will stay off school on that day to avoid having the injection regardless of what you do to promote the importance of it and the benefits of it.’ [School staff 1, school 2]
Exercising autonomy during the consent procedures
The routine procedure of initially seeking written parental consent promotes the primacy of parental consent in the HPV vaccination programme. Within this, young women play an important role in ensuring the ‘success’ of the procedures, considered as the receipt of a completed parental consent form with the immunisation team. The young woman is expected to act as a ‘vehicle to consent’ by promptly delivering the consent form to her parents or carers, ensuring they record their wishes on the form, and finally returning the consent form to the appropriate member of staff at the school ahead of the vaccination session. One parent considered this an imbalance of power and responsibility inherent within the consent procedures:
‘Even though it’s prioritising parental consent, you’re putting that responsibility on the child to get that important literature home and get it processed and get it back into school but they’re not actually responsible for it. It’s kind of quite strange.’ [Mother 6, community group 6]
Interview participants frequently commented how this process granted opportunities for young women to exercise power through intercepting consent procedures. This could be achieved by young women simply not presenting the paper-based consent form to their parents:
‘I think that’s why my daughter wasn’t like ‘mum can you sign this?’ [HPV vaccine consent form], you know, ‘cos she didn’t want it.’ [Mother 9, community group 1]
Other strategies included not returning the completed parental consent form to the school, or even filling in the consent form themselves:
‘They think if they hide the form, they don’t need to have it [the vaccine] and it’s amazing how many forms miraculously appear out of the bags when you say that you’re going to phone the parents.’ [Immunisation nurse 3]
‘Sometimes they don’t want to get it [the HPV vaccine] done so they forge the form.’ [Young woman 1, mainstream school 10]
Participants felt this behaviour would be played out if there were worries about receiving the injection, rather than strongly formed beliefs opposed to vaccinations:
‘If they’re scared the needle’s going to be really big they just won’t give it [the consent form] to their parents.’ [Daughter 2, community group 5]
‘If she [her daughter] knows it’s for an injection, she’ll probably throw it in the bin or something ‘cos that’s what she’s like. I mean that’s what most girls are like isn’t it? If they don’t want to have- well who wants to have an injection?’ [Mother 4, community group 1]
To overcome barriers to the receipt of consent forms, one school augmented the primacy of parental consent by posting forms directly to parents. Students at this school were all in agreement that this approach was warranted for the reasons discussed above. These students considered if they were to be given the responsibility to deliver the consent forms to their parents, they would still prefer the school ensure their parents were aware that they should anticipate the arrival of a consent form:
‘I think people [school staff] should get- like, if they wanted to give us the consent form, they should send home a text or ring my mum.’ [Young woman 3, mainstream school 9]
Lack of priority towards receiving the HPV vaccine meant that young women could unintentionally intercept the consent process, because they forgot about or misplaced the parental consent form. This barrier to uptake could be overcome, in part, by seeking verbal consent from parents on the day of the vaccination session:
‘I always want to give my mum the letters but I have a bad habit of putting things in my bag and then forgetting about it.’ [Young woman 5, parent verbal consent, mainstream school 9]
‘I know I had it in school but I came in the morning and I lost it ‘cos I was going to hand it in to reception but I sat down in this area and I lost it.’ [Young woman 1, parent verbal consent, mainstream school 10]
School staff and immunisation nurses suggested that a student’s background could influence the extent to which additional efforts were required to ensure compliance with consent form receipt:
‘It’s often though, the case that students who come from a more kind of disorganised background are the ones that don’t bring their forms back in. I know it’s an obvious thing to say but those that are out of routine, those are the ones where forms stay in bags or get left on the kitchen table or accidentally picked up, put in the bin and you won’t get them returned and those are the ones you’re chasing a lot.’ [School staff 1, mainstream school 2]
Despite the constraints of the school environment, and consent procedures where adults hold greater influence, in exceptional circumstances young women could use their power to ensure they received the HPV vaccine. This could be through signing on behalf of their parents, or not returning completed paperwork where their parent had refused consent:
‘We got given like a big sheet and my mum didn’t want me to get that [the HPV vaccine] or the meningitis I think, so I signed them myself and got it done anyway.’ [Young woman 1, community group 4]
‘So one in particular the young girl had come in, spoken to my colleague, gone down ringing mum, no reply, does mum want you to have the vaccine? Yes, yes, she wants me to, we just haven’t bought the form back ... Great girl, went through everything, really competent, signed her consent, someone else, another member of staff went on and gave the vaccine ... By the time we got back to the office she’d obviously rung mum then and mum had rung in absolutely fuming that she had signed, I believe she had signed as a refuser and the form hadn’t made its way to us.’ [Immunisation nurse 2]
The structures of the consent procedures could also undermine young women’s autonomy despite their willingness and advocacy to receive the HPV vaccine:
‘My mum kept forgetting. I kept reminding her but she kept forgetting to give it [the consent form] back to me.” [Young woman, adolescent self-consent, mainstream school 1]
In one case, an administrative oversight resulted in a group of vaccine eligible young women, who attended an alternative education provider co-located within a mainstream school, not being invited to receive the HPV vaccine with their peers:
‘That’s communication failure then because we’ve missed that… Ours [vaccine eligible students] have not had the letters so that’s worth- Yeah, I’ll chase it up.’ [School staff 1, alternative education setting 4]