school nurses’ strategies and experiences of including boys in the HPV vaccination programme in Swedish primary schools

HPV vaccination, young people and schools

All over the world, boys were included in HPV vaccination programmes years after girls. This has resulted in a paucity of research focusing on boys and HPV vaccination. Existing social research on HPV vaccination for boys has focused largely on policy discourses and public debate, not on the student welfare team’s and school nurses’ experiences. Nevertheless, existing research is helpful in highlighting the discourses commonly when talking about HPV vaccination for boys. Epstein (Citation2010) has argued that lack of attention to boys during the HPV vaccine’s first years was partly related to prevailing sexual morality and homophobia in the USA. Relatedly, studies from Austria have shown that when the HPV vaccine was introduced for all children in the country in 2016, efforts were made to avoid a politicised debate about sex and HPV and discussion of men who have sex with men and anal sex (Paul Citation2016). Policy officials and experts decided to present a ‘gender-neutral’ HPV vaccination programme not linked to sex, but as an example of the progressive features of the Austrian national immunisation programme (Lindén and Busse Citation2017).

Beyond the social sciences, applied health research has recently focused on parents’ and boys’ perspectives on, and experiences of, HPV vaccination programmes that include boys. Such research has shown that boys and boys’ parents express a lack of knowledge about HPV and HPV vaccination (Gottvall, Stenhammar, and Grandahl Citation2017; Grandahl et al. Citation2019; González-Cano et al. Citation2021). For example, in a US study – where the vaccine was recommended for girls and boys from the age of 11 – it was shown that while many parents are aware of the recommendation to vaccinate boys as well, they were unclear about the benefits, as they assumed the HPV vaccine was intended to prevent cervical cancer (North and Niccolai Citation2016). In studies in Sweden conducted prior to the inclusion of boys, it was shown that both parents (Gottvall, Stenhammar, and Grandahl Citation2017) and adolescent boys (Grandahl et al. Citation2019) favoured an HPV vaccination programme that also included boys. Grandahl et al. (Citation2019) showed that, for the boys they interviewed, the issue ‘was not a matter of sex but of equality and equal health’ (Grandahl et al. Citation2019). Relatedly, Mattebo, Gottvall, and Grandahl (Citation2021) conducted focus groups with school nurses who had been involved in an intervention to increase adolescent boys’ and girls’ knowledge about HPV and HPV vaccination. School nurses emphasised the importance of including boys to improve equal health and health equity in the vaccination programme (Mattebo, Gottvall, and Grandahl Citation2021).

Previous social science research on the introduction of the HPV vaccination for girls in schools has stressed the themes of gender, HPV and sex. In a study from the UK, Spratt et al. (Citation2013) found a disjunction between the policy aims of the schools as educators in sexual health and teachers’ views concerning their roles. They showed that competing discourses surrounding young women’s sexuality, concerns about relationships with parents, and wider implications for the schools led to uncertainty and confusion about roles. In the UK, 12- to 12-year-old students are the target population for HPV vaccination. In a study in Canada, Mishra and Graham (Citation2012) argued that school nurses adopted gendered framings of the vaccine. For instance, they tended to sideline the focus on HPV and sex and instead talk about the vaccine as a ‘cancer vaccine’. In Canada, the vaccine is recommended for 11- to 13-year-old students. Writing before the vaccine was introduced to boys in Canada, they argued that the side-lining of male risks associated with HPV exposure involved ‘heterosexist ideas about female vulnerability, naïveté and compliance’ (Mishra and Graham Citation2012, 66). In contrast, a recent study from Finland, Virtanen and Salmivaara (Citation2021) showed that school nurses criticise such stereotypical views of girls. The school nurses they interviewed questioned the heteronormativity and ‘pink-ness’ of the official Finnish information campaign, arguing that boys too should also be offered the vaccine. In Finland, boys have recently been included in the HPV vaccination programme, and today 11- to 12-year-old students (both girls and boys) comprised the target population. Finally, an Australian study demonstrated that educational interventions can increase students’ knowledge about HPV and HPV vaccination (Davies et al. Citation2017). Davies et al. also showed that HPV educational interventions are straightforward to implement in schools. They argued that HPV vaccination education addressing HPV, sex and sexual relations should be provided for all students. The Australian national HPV vaccination programme was implemented for girls in 2007 and for boys in 2013, with 11- to 14-year-old students.

In research on experiences and views concerning HPV vaccination in schools, it has been shown that girls’ and young women sometimes position themselves as capable of ‘taking on’ the responsibility placed on them to prevent sexual risks, but at other times stress the problems of only vaccinating girls and placing the responsibility on them (Polzer, Mancuso, and Laliberte Rudman Citation2014; Wyndham-West Citation2016). For example, Virtanen and Salmivaara (Citation2021) revealed that girls in Finnish primary schools understood the vaccine as a ‘girls only’ product through a sense of empowerment and privilege, but is also showed that the girls had little knowledge about the connection between sex, HPV and cancer.

Studies have shown that parents navigate their perceived responsibility for vaccination in ways that both include and exclude a focus on their daughters’ (future) sexual relationships (Rail et al. Citation2018). For example, Albert (Citation2019) argued that mothers may hold sometimes contradictory opinions concerning female sexual behaviour to make sense of their vaccination decision. Several of the US mothers she interviewed had decided to vaccinate their daughters on the assumption that their daughters’ innocence was at risk due to boys’ premarital promiscuity. In relation to parents’ rejection of the HPV vaccine, Reich (Citation2016) revealed that parents encouraged their children (especially daughters) to eliminate the risk of getting infected with HPV by remaining sexually abstinent until married. The possibility that their children might be the victim of sexual assault was never brought up by the parents.

Current study, method and analysis

This article draws from a study of 21 in-depth interviews with school nurses working in 21 different school districts in 20 different municipalities in one of Sweden’s largest regions.³ We found a case-study approach to be particularly appropriate, given that we want to analyse and understand a certain complex phenomenon (Yin Citation2014). The project was located to one region, and this region is chosen for two specific reasons. First, it allowed us to study how the implementation is carried out in a region that included a greater metropolitan area, mid-size towns, small towns and rural areas (see Table 1 below). Several reports have revealed geographical differences in the quality of the school health services in Sweden, and shown that these differences greatly affect students’ experiences (Swedish Government Citation2018). Second, the region was interested in developing a ‘sex positive’ approach to their work with HPV vaccination, and this contrasts with findings from research on the vaccination for girls, where a ‘sex negative’ approach focusing on sexual risks has been common (Lindén Citation2016). Therefore, this region provided a suitable case for investigating the implications of boys’ inclusion for gender equality.

The study is part of a national research project that aims to generate knowledge about how the extended HPV vaccination programme, which now also includes boys, is being implemented in Swedish primary schools. A specific focus of this work is on investigating the programme’s implications for understandings and practices of gender equality and sexual health among young people.

An application was submitted to the Swedish Ethical Review Authority [Dnr. 2020–06051] before the study could be conducted. The board approved the application in December 2020. Following approval, potential participants were contacted and informed about the study. School nurses were contacted through personal phone calls and emails, and all 21 participating school nurses gave their written, informed consent. To ensure confidentiality, all participants are referred to as ‘school nurse’, also the names given to municipalities and school districts are pseudonyms (Vetenskapsrådet Citation2017). To specify which informant says what, the pseudonym for the municipality and for the school district are included in brackets in the end of each quotation.

We began work during the Covid-19 pandemic, and due to national restrictions, all interviews were conducted online via video calls. This enabled us to cover a much larger geographic area of the region than initially intended. The interviews were conducted in Swedish between March and May 2021. YO conducted 11 interviews and LL conducted the remainder of them. All interviews were audio recorded, fully transcribed by a professional freelance transcriber, and translated into English by the authors. The interviews lasted about an hour on average, generating approximately 21 hours of audio recorded material. Semi-structured interviews were selected for the present study, as they allowed pre-structured issues to be discussed, while at the same time allowing for digression and elaboration (Alvesson Citation2011). The interview guide covered questions concerning school demographics, the inclusion of boys in the vaccination programme, school nurses’ practical work with the vaccinations, and strategies for reaching out to and informing the students and their guardians about the new vaccination policy, about HPV, sex, sexuality and cancer.

Thematic analysis was identified as the most appropriate approach to analysing the empirical data (Braun and Clarke Citation2006). It involves a step-by-step process, and our analysis included five main steps. The authors jointly: 1) read all the transcripts multiple times to become familiar with the data, 2) coded and anonymised the data, 3) discussed and analysed recurrent themes, i.e., searching for themes connected to HPV, sex and equal health, 4) analysed and organised the data into main themes and, finally, 5) theorised the data. During this five-step analytic process, two key themes were developed: 1) Sex, sexuality and HPV, and 2) Gender, age and respectability.

Drawing on feminist theories on respectability and heteronormativity, this study analyses the kinds of gendered norms and assumptions about HPV, sex and sexuality that are present in school nurses’ narratives. In conducting our analysis, we found Butler’s work on heteronormativity particularly useful. Following Butler (Citation2007), the ‘compulsory’ nature of heterosexuality is something that all people, regardless of gender and sexual orientation, must engage with on a daily basis. Heterosexuality is positioned as natural, legitimate and desirable within society’s sociosexual hierarchy (Butler Citation2007).

We also found ‘respectability’ to be a useful theoretical concept. Respectability builds on moral judgements connected to issues of gender, sexuality, ethnic background and social class (Skeggs Citation2002). Moral judgements often contain views about representations of femininity and girls’ behaviour and appearance. Recent research argues that girls, irrespective of social class, are expected to a conform to proper heterosexual femininity, and that girls who fail to do so are marginalised (Woolley Citation2020). This understanding of respectability is useful when addressing moral assumptions and norms concerning how students eligible for HPV vaccination ought to behave sexually, not least in relation to assumptions about children being asexual (Renold and Ringrose Citation2013).

Sex, sexuality and HPV

School nurses in the study described similar routines for informing students and their guardians about the HPV vaccination: The guardians received an information letter and a letter of consent that they were asked to sign and return to the school. The vaccination for the children was voluntary, meaning that the guardians could either give or decide not to give their written consent for their child to be vaccinated. According to nurses in the study, over 90%, and in some school classes even 100%, of students received the HPV vaccination. While this is slightly higher than the overall national statistics for the HPV vaccination programme, it nevertheless reflects the high vaccination acceptance rates in Sweden (Public Health Agency of Sweden Citation2021).

According to participants, students are informed about HPV by school nurses in the classroom. Beyond this, the school nurses did not report collaborating with the teachers in informing students about HPV and the HPV vaccination. When they did so, students are given the opportunity to ask questions about HPV and how the vaccination is performed. Because HPV is transmitted through sex, school nurses discuss the topic of sex and sexuality with the students. How detailed an approach they take to discussing this topic with the students varies however.

Other school nurses went into more detail when discussing what sexually transmitted infections (STIs) are. They also brought up the importance of protecting yourself and practising safe sex.

This understanding of and connection to cancer is in line with previous research showing that the HPV vaccine is often framed as a ‘cancer vaccine’ (Lindén Citation2016). In the interviews, the cancer dimension of the vaccine was often expressed as something the school nurses assumed the students understood well. In contrast, with HPV, they had to explain a bit more. The school nurse at the above school reported informing the students that HPV is transmitted through sex and talking about how to protect yourself. She also said she mentions that she will talk more about STIs during ‘the puberty talk’. Depending on the school’s organisation, school nurses often inform the students about puberty, sex and sexuality. ‘The puberty talk’ is a specific occasion that takes place during the fifth or sixth school year (students aged 11–12). In some of the participating schools, this responsibility is now assumed by the teacher and is part of sexuality, consent and relations education.⁴

Other school nurses in the study talked about the importance of practising safe sex when informing the students about HPV.

Safe sex is not the only thing this school nurse stressed; she also underlined the importance of getting the HPV vaccine. Even though the school nurse reported not having thought particularly about the boys, it seemed rather self-evident that they too should receive the HPV vaccine.

Issues of sexuality and gender identity are stressed in Sweden’s national curriculum and serve to provide the policy context for school nurses’ attention to HPV and sex. In line with the national curriculum, all forms of discrimination should be addressed: ‘No one should be subjected to discrimination on the grounds of gender,/…/transgender identity or its expression, sexual orientation, […] ’ (Skolverket Citation2018, 5). ‘The puberty talk’ mentioned previously and the subject of sexuality, consent and relationships are aligned not only with the fundamental values and responsibilities of the school, but also the core content of biology and civics in years 4–6. In the biology syllabus, the core content deals with: ‘Human puberty, sexuality and reproduction as well as questions of identity, gender equality, relationships, love and responsibility’ (Skolverket Citation2018, 169). In civics, the core content focuses on: ‘The family and different forms of cohabitation. Sexuality, gender roles and gender equality’ (Skolverket Citation2018, 230).

With respect to sexual relationships and sexuality, only one school nurse mentioned sex between non-heterosexuals, and did so implicitly making reference only to boys:

As shown in the extract above, non-heterosexual sexual relations were essentially absent from the narratives. School nurses also suggested that the students are well-informed and understood the complex links between sex, HPV and cancer, assuming that their lack of questions was a sign that they possessed the required knowledge and, thus, was not a problem. Yet one critical question that might be asked is whether this silence might instead be related to students finding it difficult, awkward and perhaps embarrassing to ask questions about HPV, sex and sexuality.

The vast majority of school nurses in the study discussed the connection between sex and HPV, but a few exception reported avoiding the link completely. Similar to findings in previous research on school nurses’ views (Mishra and Graham Citation2012), the focus was placed on cancer and not HPV.

The results reveal results reveal that in informing children about sex, different sexual relationships and identities are more or less absent from the narratives. This absence could be interpreted as reflecting a strongly heteronormative understanding of sex and sexual relations. In this respect, our findings contrast with those of Virtanen and Salmivaara (Citation2021) in Finland, who found that school nurses questioned the heteronormative framing of the HPV vaccine. The lack of serious questions from the students may also say something about the difficulty of informing young people about sex, sexuality and HPV in a pedagogic and comprehensible way. Discussing these matters in front of others is not necessarily easy for students, which may explain why they did not ask many questions. Finding other ways to talk about these issues with students – and approaches that can make students feel more comfortable posing questions about and discussing these issues – may therefore be the way to go.

Gender, age and respectability

According to school nurses, including boys in the HPV vaccination programme had been quite unproblematic. Irrespective of social background, boys’ guardians had generally been positive about the vaccination, and no guardians have questioned why boys were now included in the programme. Instead, it was more common for school nurses to experience hesitation and receive questions about the vaccination from girls’ guardians. Even though they were exceptions, these narratives were framed in terms of age.

According to school nurses, guardians’ main argument for not vaccinating their daughters in the fifth school year was that they are too young. These narratives based on an understanding of the respectable and asexual child (Renold and Ringrose Citation2013), in line with findings from previous research (Reich Citation2016; Albert Citation2019; Spratt et al. Citation2013). Mentioning girls’ young age in relation to their sexuality was also discussed by other nurses.

Another school nurse said:

Some guardians’ decision not to vaccinate their daughters linked to the family’s religious beliefs. This was particularly the case for Christian families living in rural communities.

Heteronormativity also framed the narratives. Even though the focus was on their daughters, the future husband’s sexual abstinence was sometimes mentioned by parents.

Other families that did not wish to vaccinate their daughters were those from an immigrant background. Here, school nurses explained the guardians’ decision in relation to the families’ cultural and religious background.

Similar views were present in other narratives.

We can see here how ‘the respectable girl’ frames the narratives of families categorised as immigrant families, in which girls are expected to have only one future sexual partner. Another dimension the school nurses addressed is boys’ sexuality. According to the school nurses, boys with an immigrant background have more sexual freedom than their female counterparts do. Boys may have had several partners before marriage, according to the school nurses. By claiming that immigrant boys may have had several sexual partners, immigrant boys are positioned not only as the Other, but also as sexually free.

In placing the focus on girls’/daughters’ sexuality, the narratives can also be understood and interpreted in relation to responsibility. By claiming one’s daughter is sexually abstinent, the girl is positioned as responsible not only for her own sexual health, but also for protecting a future partner against HPV. While previous research (e.g., Mishra and Graham Citation2012 has shown that HPV vaccination programmes position girls as responsible for managing their sexual health, school nurses’ narratives suggest a gendered responsibility may remain in the case of an extended vaccination programme including boys. Also absent from the narratives was the possibility of daughters being the victims of sexual assault, which could result in HPV infection (Reich Citation2016).

Recurrent throughout the narratives was a strongly traditional and heteronormative view of sexuality. When school nurses described guardians’ understanding of sexuality, the accounts they shared were framed by heteronormative assumptions not only about young people’s sexuality but also girls’ respectability (Butler Citation2007; Skeggs Citation2002; Renold and Ringrose Citation2013; Woolley Citation2020). The possibility of non-heterosexual relations was never discussed.

Discussion

In this article, we have addressed issues of gender, sex and sexuality in the implementation of a new HPV vaccination programme which includes all fifth-year students in 21 Swedish primary schools. The study is the first from Sweden to focus on school nurses’ experiences working with an HPV vaccination programme that also includes boys. Given the scarcity of research focused on the student welfare team’s and school nurses’ experiences of boys and HPV, both in Sweden and internationally, the study adds new knowledge to the field.

The results suggest that including boys in the vaccine programme has been relatively unproblematic. In situations where school nurses encountered hesitation concerning vaccination, this was mostly in relation to girls. The child’s age was argued to be the main concern for guardians. These narratives are framed based on notions of the respectable girl, with it being argued that the daughter is too young to have sex [with a boy] (Woolley Citation2020). This gendered double moral standard concerning sexual agency and responsibility says something about existing gender norms, views on sexuality as well as heteronormative understandings of sexuality.

Moreover, only heterosexual relations are mentioned in these narratives. When reference to these were made, the focus was only on gay men. While this is to a degree understandable given public debate about discrimination towards men who have sex with men in the former HPV vaccination policy, it raises questions about the status of lesbian, bisexual and other relationships as well as young people’s different (e.g. cis, trans, transgender, transsexual, genderfluid or asexual) gender and sexuality identities. The key question here is this, is this topic simply forgotten about, or is it avoided by school nurses? Such findings are perhaps best understood both in relation to school nurses’ struggles to address HPV and sex pedagogically, and in relation to the prevailing heterosexual hegemony in Swedish society (Butler Citation2007).

It is important to recognise that this study was conducted during the COVID-19 pandemic, which means that all interviews had to be conducted online via Teams or Zoom instead of face-to-face at the respective schools. A positive consequence of this was that we were able to conduct a much larger number of interviews than might otherwise have been the case. It also enabled us to cover almost the entire region, instead of only conducting interviews at a few schools. One possible negative outcome of conducting interviews online, however, is the social distance it creates. For some of the respondents, face-to-face interviews may have been an easier format in which to talk about work experiences.

Conclusion and next steps

Findings from this study have implications for school nurses’ everyday work as well as for sexuality, consent and relations education. Informing young people about and discussing HPV and sex with students provide opportunities for raising questions about equal health, the shared responsibility for protecting each other when having sex, as well as the importance of mutual consent. However, there are also challenges associated with this work that must be addressed. It is only by listening to and analysing students’ narratives that we can begin to understand their point of view regarding these issues. Further investigation requires us to conduct interviews with students themselves – and this is also something we plan to do later in this project.

To address questions of sexual identity, it is important to discuss HPV and sex in a manner that includes students/people who identify themselves as LGBTQ+. If this is rarely or never done, there is a risk that students who identify as LGBTQ+ will be discriminated against. Considering what is stated in the national curriculum about combating different forms of discrimination in school, it is problematic if these issues are forgotten about or ignored (e.g., Skolverket Citation2018). Moreover, considering that the new HPV vaccination programme is intended to prevent a range of HPV-related cancers, such as anal and throat cancer, the programme creates an opportunity to discuss sexual practice from a non-heteronormative perspective, i.e., that sex can be practised in a multitude of ways. Nonetheless, the heteronormative understanding of sexual relations present in the school nurses’ narratives suggests that this opportunity is not being grasped by school nurses and that they struggle with these matters. This underlines the importance of school nurses as well as other school officials receiving further education about how to address issues of sexuality, sex, safe sex and HPV. Finally, our findings underline the importance of further aligning information about the HPV vaccination with sexuality, consent and relations education in primary schools, as this setting provides the opportunity to discuss HPV and sex in more depth and at a slower pace.