INTRODUCTION

In general, the issue of vaccination has always been a subject of concern (Gottlieb, 2018; Hausman, 2019), and concerns can be specific to both a particular vaccine and a particular country (Edelstein et al., 2020; Hausman, 2019). In this article, I explore vaccination against human papillomavirus (HPV) in Denmark. Concerns about HPV vaccination have differed across countries. For instance, in Israel, Malaysia, the United States and the United Kingdom, being vaccinated has been linked with concerns over promiscuity and risky sexual behaviour (Fisher et al., 2013; Li, 2011; Marchand et al., 2013; Marlow et al., 2009; Warner et al., 2017). In Denmark, however, concerns have been focused on potential side effects of the vaccine (Suppli et al., 2018).

As such, HPV vaccination includes social complexities – also in Nordic welfare countries (Lindén, 2016; Virtanen, 2019). Understanding some of these social complexities is the focus of this article, in which I aim to explore: How do Danish parents engage with digital media in different Discourses when struggling to make a decision about HPV vaccination?

STRUGGLING TO MAKE DECISIONS ABOUT A COMPLEX HEALTH ISSUE

In Denmark, HPV vaccination started in 2008 (Sander et al., 2012), and the vaccine was subsequently introduced in a voluntary, free-of-charge childhood vaccination program for girls in 2009 (Suppli et al., 2018; Widgren et al., 2011). In this vaccination program, vaccines are typically administered by the child's general practitioner (Sander et al., 2012; Suppli et al., 2018), and parents typically have to make an appointment with their child's general practitioner to have their child vaccinated. Vaccination rates, in general, are high in the Danish childhood vaccination program. For instance, since 2000, MMR vaccination rates have been above 80 per cent amongst all Danish children (SSI.dk, NA). Initially, the HPV vaccine also had an expectedly high uptake in Denmark (Suppli et al., 2018; Widgren et al., 2011). However, in 2014, HPV vaccination was the subject of concern and media coverage, correlating with a decline in vaccination uptake (Suppli et al., 2018). The low uptake was addressed with a campaign launched in 2017 designed to increase health literacy levels in order to raise public awareness about the vaccine (euro.who.int, 2019; Suppli et al., 2018). The success of the campaign resulted in a subsequent rise in vaccination uptake.

Although vaccination uptake has risen, it can still be a struggle for the individual parent to decide on opting for the vaccine and to feel confident in that decision. This can potentially be due to discursive struggles surrounding the Danish HPV vaccination program. ‘Discursive struggle’ is a term used by Mohr and Frederiksen (2020). The term refers to the existence of ‘opposing discourses of risk’ (Mohr & Frederiksen, 2020: 1046). In this study, the risks are those found in Danish public platforms relating to the HPV vaccination. The struggle thus stems from a discrepancy. Mohr and Frederiksen (2020) elucidated these discursive struggles by analysing, first, information texts from the Danish Health Authority; second, a TV documentary questioning how the authorities handled a group of girls' suspicion of side effects; and, third, the Health Board's guidelines for health professionals regarding the public attention on possible side effects (Mohr & Frederiksen, 2020). In their analysis, Mohr and Frederiksen found that the texts point to a very complex perception of the HPV vaccine in Denmark. As a result of these discursive struggles, Mohr and Frederiksen argue that the ambivalence in the presentation of risks ‘makes it difficult for parents to make a well-informed choice based on facts’ (Mohr & Frederiksen, 2020: 1054). Making this choice is further complicated by some doctors having expressed concerns about the HPV vaccination (Boysen, 2016; Mohr & Frederiksen, 2020; TV2, 2015).

As such, individuals should themselves be able to manage the risks experienced with HPV and HPV vaccination. In twenty-first century society, individuals are obliged to act as biological citizens. According to Rose, a biological citizen is someone who must understand current and potential illnesses and make decisions based on these understandings (Rose, 2007). In relation to HPV vaccination, the parents – as active responsible biological citizens – are expected to understand their daughters’ susceptibilities to illness in regard to both the vaccine and the virus.

When the interviews for this study, which I will introduce later in the article, were conducted, the national campaign aiming to raise vaccination rates had already been launched, which made authority recommendations regarding HPV vaccination clear. Nevertheless, not all parents automatically accepted the vaccine. However, to understand vaccination scepticism, Hausman (2019) argues that it is important to understand the scepticism not merely as fundamental irrationality. Consequently, by studying how parents engage with digital media in different Discourses, I seek to understand and bring new perspectives to some of the sociocultural aspects that lie behind the parents' decision-making.

A SOCIOCULTURAL PERSPECTIVE ON LITERACIES

Literacy is considered a condition of being an informed decision maker who is competent in making decisions. In turn, making good decisions maximises one's opportunities (Lunt & Livingstone, 2012). In the context of digital media and health, different researchers have presented literacy as the skills required to address or solve a health problem whilst engaging with digital media. A frequently cited understanding is one by Norman and Skinner (2006), who present eHealth literacy as six skills needed to be literate. These skills are analytic skills and context-specific skills. In terms of analytic skills, they name traditional literacy, media literacy and information literacy. In terms of context-specific skills, they name computer literacy, scientific literacy and health literacy (Norman & Skinner, 2006). As such, Norman and Skinner present an operationalised understanding of literacy in which individuals must have certain skills in order to be considered literate.

In this article, I instead understand literacy from a sociocultural perspective in which literacy is viewed as socially organised practices (Lankshear & Knobel, 2008). Lankshear and Knobel state that ‘[e]ngaging in these situated practices where we make meanings by relating texts to larger ways of doing and being is engaging in literacy – or, more accurately, literacies, since we are all apprenticed to more than one’ (Lankshear & Knobel, 2008: 7). Specifically, Lankshear and Knobel define literacies – in plural – as ‘socially recognized ways of generating, communicating and negotiating meaningful content as members of Discourses through the medium of encoded texts’ (Knobel & Lankshear, 2008: 249). Analysing literacies as socially organised practices will therefore create an understanding of how parents perceive the process of making complex decisions about their children's health. Furthermore, it will create new perspectives on why individuals engage with digital media in certain ways in relation to a complex health issue. The ‘D’ in ‘Discourses’ is capitalised here as Knobel and Lankshear follow Gee's notion of the term. Gee distinguishes between lower case ‘d’ discourse and upper case ‘D’ Discourse. Whereas lower case ‘d’ discourse refers to language-in-use, a upper case ‘D’ Discourse refers to the ability to ‘enact specific socially recognisable identities engaged in specific socially recognisable activities’ (Gee, 2015: 171). Gee further explains that ‘[b]eing in a Discourse is being able to engage in a particular sort of “dance” with words, deeds, values, feelings, other people, objects, tools, technologies, places and times so as to get recognised as a distinctive sort of who doing a distinctive sort of what. Being able to understand a Discourse is being able to recognise such “dances”’ (Gee, 2015: 172).

In my research, I primarily focus on parents' engagement with digital media in their struggle to become informed decision makers. In Denmark, the Internet is considered an important source of health information (Kummervold et al., 2008; Tassy et al., 2020), and compared to other populations in the European Union, Danes are heavy users of the Internet when searching for health-related information (Tassy et al., 2020). Because of this relatively heavy engagement with the Internet to search for health information, it is important to understand how Danish parents actually engage with digital media in their potential struggle to engage in literacies when making decisions about HPV vaccination. This can help understand what lies behind their decision-making.

METHODOLOGY

The findings of my analysis are based on interviews with 18 Danish parents of girls aged 10–13 years old. The parents were recruited through schools and snowball sampling, and interviews were conducted between January 2018 and June 2019 – a time when HPV vaccination rates had started rising again after having dropped following the media attention. The parents were recruited for interviews about how they came to a decision regarding HPV vaccination for their daughters, and I specifically searched for parents who were either currently deciding on the vaccine or who had recently made a decision about it. All parents consented to participating in the study. The interviews lasted between 44 minutes and 1 h and 59 min and were conducted in a place of the parents' choosing, such as their home, a café or their place of work.

I interviewed parents with educational backgrounds including short-cycle, further and higher education, vocational training and parents with basic school education. The majority of parents interviewed (n = 16/18) were mothers. Studies from other Western countries show that mothers often make decisions about HPV vaccination (Albert, 2019; Grandahl et al., 2017; Kemberling et al., 2011), and though I cannot conclude whether this is why it was more difficult to recruit fathers than mothers, it may be an influencing factor. Consequently, in order to ensure anonymity, the parents in this article will not be mentioned in terms of gender (mother/father/gendered names/gendered pronouns). Rather, all parents will be referred to by the gender-neutral word parent as well as names that are gender-neutral in the English language.

In this study, I have talked to parents only and not the girls (potentially) receiving the vaccine. However, when decisions about HPV vaccination are being made for adolescents, previous studies have found that parents and adolescents often discuss the vaccine together (Brabin et al., 2009; Griffioen et al., 2012), and girls have been found to discuss the topic with each other online as well (Virtanen, 2019). In a study by Griffioen and colleagues, it was also found that both adolescents and parents specifically state that the decision about the vaccine is mutual, involving both parents and adolescents. Similarly, in a report conducted by the Danish Cancer Society, some Danish parents also state that they discuss HPV vaccination with their daughters, and daughters may be involved in making the decision about the vaccine (Jakobsen, 2016). Nevertheless, Danish girls are rarely solely responsible for making the decision about the vaccine (Jakobsen, 2016), as is also the case in Griffioen and colleagues' study (Griffioen et al., 2012). A great number of Danish parents, on the other hand, (and especially mothers) claim to be primarily in charge (Jakobsen, 2016). These results are consistent with other studies in which many parents also state that they primarily make the decisions (Griffioen et al., 2012; McRee et al., 2010). As such, the results of the Danish report and previous studies point to parents almost always being actively involved in making the decision about whether or not to vaccinate. This is not always the case for daughters. Consequently, parents almost always play a very important role in adolescent HPV vaccination (Brabin et al., 2009; Griffioen et al., 2012; Virtanen, 2019). Due to the parents' prominent part in making the decision about HPV vaccination, they are the focus of my study.

All interviews were transcribed verbatim, and further data processing was conducted using the computer-assisted qualitative data analysis software NVivo. The analysis was conducted in two steps. Initially, I coded the entire data set according to the elements the parents deemed pertinent in the interviews (Nordtug, 2020). I understand ‘elements’ here as everything that constitutes a situation, that matters in a situation or that makes a difference in a situation (Clarke et al., 2018). Based on an analysis of the relations between selected elements, and following Clarke et al., (2018), I found that the following topics warranted further investigation: (1) the parents' explanation of what it means to be well informed when making a decision about HPV vaccination, (2) parents' experiences with engaging in literacies and 3) parents' engagement with digital media when engaging in literacies. Secondly, I then coded these three topics into the following corresponding subsets: (1) twelve codes including ‘being source critical’, ‘reading a large amount of information’ and ‘talking to health professionals’, (2) eleven codes including ‘difficulty’, ‘time consuming’ and ‘ease’ and (3) six codes including ‘searching for information’, ‘interpersonal communication’ and ‘reading/viewing/listening’. Consequently, based on these codes, I was then able to interpret the data, thereby identifying: first, the Discourses that I will present in the analysis; second, the parents' discursive affiliations; and third, how parents engage with digital media when deciding on HPV vaccination. In combination, these codes can help point to an understanding of how being affiliated with specific Discourses may influence how parents engage with digital media. This can then provide new perspectives on why individuals engage with digital media as they do in relation to making decisions on complex health issues. All interviews were analysed individually in their full length in order to take into account nuances in the individual parents' statements and opinions.

ANALYSIS: ENGAGING IN LITERACIES

The analyses of the interviews show that the parents engage in literacies in different ways when making decisions about HPV vaccination. In the following analysis, I identify two Discourses the parents appear to be members of when making this decision. Following Knobel and Lankshear, I understand Discourse here as ‘the underlying principle of meaning and meaningfulness’ (Knobel & Lankshear, 2008: 257). Knobel and Lankshear explain that individuals ‘“do life” […] as members of social and cultural groups […] which can be understood as meaningful co-ordinators of human and non-human elements’ (Knobel & Lankshear, 2008: 257). As such, being a member of a Discourse in relation to making decisions about HPV vaccination entails acting according to identifiable discursive affiliations (Knobel & Lankshear, 2008). I have interpreted the ways that parents employ digital media as belonging to two Discourses, which I identified inductively from the interview data. In the following analysis, I interpret the parents' discursive affiliation in relation to making decisions about HPV vaccination taking into account the nuances both Discourses contain. Within each Discourse, I analyse how parents engage with digital media in their struggle to make a decision about HPV vaccination. Consequently, this analysis will help give a deeper understanding of why parents engage with digital media the way they do in relation to such complex health issues.

In the first Discourse, I identify that parents point to a centralised way of engaging in literacies, and in the second Discourse, I identify that parents point to a more decentralised way of engaging in literacies when making their decision.

DISCUSSION AND CONCLUSION: THE NECESSITY OF ENGAGING IN (DEMANDING) LITERACIES

As I show in the analysis, the parents' experiences of engaging in literacies differ. Whereas some parents find it rather easy, engaging in literacies is to some considered (too) demanding or overwhelming. In fact, some parents feel that they are unable to engage in literacies to a satisfactory extent either because it is too time-consuming or because of an experienced inability. As such, those who are members of a decentralised Discourse appear to struggle more than those who are members of a centralised Discourse. The requirements of being a responsible biological citizens may thus be too demanding (Rose, 2007).

The Danish authorities clearly recommend the HPV vaccine (SST.dk, 2019), and yet have wanted to increase ‘health literacy so that people could make an informed medical choice about the vaccine’ (euro.who.int, 2019). This desire by the authorities to increase literacy in parallel with their recommendation to vaccinate against HPV might appear to mutually trivialise each other. Why do Danish parents need to struggle to make complex health decisions when there is a clear recommendation as to what authorities believe they should do?

This parent refers to a need to read and trust a scientific study, as the authorities might hide information from the public. Furthermore, this parent also suggests why it is important to understand the available information, namely because it is the only way to be sure of getting the information one needs. Another parent mentions the possibility of health professionals not being good enough at their jobs to give adequate advice: ‘Just, you can't be sure that, like we talked before about how there are bad plumbers and there are bad anything else, and you can't be sure that your general practitioner is the best in the world’ (Jess). These findings provide new perspectives on why parents have differing approaches to engaging with digital media in relation to health issues: Different discourse affiliations demand different kinds of engagement. Digital media contain a great deal of information about health issues, and not engaging with some of that information in a decision-making process may be experienced as irresponsible, or – in Rose's terms – as though one is not living up to one's responsibility as a biological citizen (Rose, 2007).

The fears and concerns mentioned above further point to why it might be necessary to go through the struggle of engaging in literacies. As suggested by Rose (2007), individuals have to manage their – and their children's – risk of disease. When discursive struggles exist in the Danish HPV vaccination situation (Mohr & Frederiksen, 2020), the parents have to deal with the different risks they are presented with. This can lead to parents not complying with government recommendations. For instance, in an Israeli study on child vaccinations amongst parents of children aged 3–4 years old, Aharon et al., (2017) found that high health literacy levels were associated with noncompliance with governmentally recommended vaccination. Thus, the individualisation of responsibilities might present problems for actors such as policymakers, ‘when citizens do not make the “right” choices’ (Nettleton, 2013: 53). Similarly, in Denmark, ‘girls born to mothers with the highest level of education had the largest decline, in particular for HPV1 coverage’ (Gørtz et al., 2020: 4). As such, there is an inherent paradox. Parents are expected to actively manage the risks associated with HPV and HPV vaccination. However, should the parents' risk assessment contradict the authorities' risk assessment, the parents' assessment would be considered wrong. A similar paradox is found in Virtanen's study on the framing and taming of HPV vaccination in Finland (Virtanen, 2019). In Virtanen's study, some adolescent girls in online discussions challenged the rationality of HPV vaccination, and this questioning ‘was based on the very framing of the official vaccination campaign by stressing one's competence as a self-responsible, rational health-subject’ (Virtanen, 2019: 801). However, Virtanen also finds that in the Finnish HPV vaccination campaign materials, getting vaccinated was presented as the rational and responsible way for girls to take care of their health. As articulated by Hausman: ‘Responsibility is necessary and good, therefore, unless the enactment of it leads to behaviors that contravene socially normative expectations’ (Hausman, 2019: 83).

Although lines of force are shaped to make it more likely that parents vaccinate (Foucault & Senellart, 2007), Danish parents are free to decide if they wish to follow authority guidelines on vaccines. Having this ability to choose whether to follow authority recommendations can be understood as an empowerment of the recipients of medical care (Rose, 2007). This empowerment enables individuals to make choices that might appear irrational (Rose, 2007), but as the analysis in this article shows, the empowerment might also leave individuals struggling to find out whether the recommendations put forward by authorities are in fact to be trusted. Individuals are ‘obliged to take responsibility for their own medical futures and those of their families and children’ (Rose, 2007: 29). As the responsibility for health is placed upon individuals, the parents' experienced need for engaging in more demanding literacies might increase. Engaging in literacies can become a struggle in which parents can seek help from digital media, but, as the analysis shows, the engagement with digital media can pose a struggle in its own right. The many sources upon which parents are able to base their perceptions thus bring about struggles (Davison et al., 1991; Frankel et al., 1991; Mohr & Frederiksen, 2020). However, the parents' experience of responsibility suggests why they themselves feel the need to struggle: The need to struggle seems to arise partially due to a fear that authorities might withhold information from the public, or because of a fear that health professionals do not do an adequate job. Arguably, engaging in demanding literacies then becomes a precaution against a potentially flawed health system as well as being a precaution against an inability amongst parents to simply trust authority recommendations. However, the need to struggle may also partially stem from the parents' experienced demands, which are shaped by the Discourse. The Discourses are formed through the actions of the parents, and through these actions, it appears that struggles to engage in literacies and struggles with digital media are necessary. This might explain why individuals who (choose to) trust the health system and rather uncritically follow authority recommendations do not appear to struggle to make a decision about HPV vaccination. They might have a trust in the system that deems demanding work in terms of literacies to be redundant, whilst others, whose Discourse affiliation is formed through a more demanding set of actions, might experience a (potentially unachievable) responsibility to be as well informed as, or even better informed than, the health authorities.

AUTHOR CONTRIBUTIONS

Maja Nordtug: Conceptualization, analysis, writing and editing.

ETHICAL APPROVAL

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