Authors: Māra Grīnfelde, Uldis Vēgners, Andrejs Balodis
Categories: Research, Embodiment, Phenomenology, Disease prevention, Nonadherence, Preventive health behaviour, Objectification
Source: Philosophy, Ethics, and Humanities in Medicine : PEHM
Authors: Māra Grīnfelde, Uldis Vēgners, Andrejs Balodis
Many studies have used ideas from phenomenological philosophy to explore health and health care, yet topics related to public health have often been overlooked. We argue that at least one crucial issue in public health—the question of adherence (or lack thereof) to preventive health measures—can benefit from a phenomenological perspective. While numerous studies have examined the factors influencing adherence, none have addressed the role that embodiment plays in shaping adherence. Building on existing phenomenological research on adherence, we demonstrate that phenomenology can offer a novel, embodied perspective on this issue.
This article draws on data from our phenomenologically grounded empirical study on COVID-19 vaccine hesitancy, which involved 16 in-depth interviews with individuals reluctant to receive the COVID-19 vaccine. However, the aim of this article is not to present the specific findings about vaccine hesitancy. Instead, referring to both theoretical research within phenomenological tradition and interview data, we seek to generate new insights into the motivational orientation toward preventive health measures more broadly.
We demonstrate that adherence to a preventive measure depends on the type of bodily objectification involved—whether it is good or bad objectification. Good objectification involves a focus on one’s body that is compatible with one’s subjectivity, whereas bad objectification involves a focus on one’s body that disrupts subjectivity. We conclude that from an embodied perspective, nonadherence is grounded in a person’s wish to avoid the disruption of her subjectivity.
By recognizing the role that our embodied being in-the-world plays in our willingness or unwillingness to comply with preventive measures, this study offers a deeper understanding of the embodied motivation behind adherence and provides insights for both developing strategies to enhance adherence to preventive health measures and new directions for future phenomenological research in relation to public health.
In the last few decades, many studies have used insights from phenomenological philosophy to examine issues relevant to health care, resulting in the development of phenomenologically grounded health care strategies for rehabilitation [1], for the treatment of individuals with concrete health issues (e.g., cerebral palsy [2], hemispatial neglect [3], disfigured bodies [4], schizophrenia [5] and anorexia nervosa [6–7]), and for the development of phenomenological toolkits designed for patents and clinicians to improve the quality of patient care [8–10]). These studies have been both theoretical and empirical, with the aim of improving the quality of care. Despite this interest, phenomenologists, for the most part, have been hesitant to address topics related to public health. This reluctance may stem from the seemingly conflicting orientations of public health and while public health adopts a collective, population-based approach, phenomenology has centred on the individual or the group. In this article, we demonstrate that at least one set of issues relevant to public health can benefit from a phenomenological perspective—the question of adherence (or lack thereof) to preventive health measures. This question fits within a broader topic of preventive health behaviour1, which is defined as an “activity undertaken by a person who believes himself to be healthy for the purpose of preventing disease” [11].2 Psychologists, sociologists and public health scientists [12, 15–18] have studied both sociodemographic characteristics and psychosocial factors influencing preventive health behaviour and, more concretely, trying to determine why people do or do not adhere to preventive health measures. With respect to sociodemographic characteristics, research suggests that age and gender are significant contributing factors to adherence; i.e., women are more likely to adhere to preventive measures than men are, and greater age is associated with greater adherence [19–20]. Other factors suggested to contribute to adherence behaviour are education, cultural values and socioeconomic status [16, 21]. With respect to psychosocial factors, research suggests that efficacy beliefs [19, 22], risk assessment [23–24], trust in institutions [19, 20, 23], normative beliefs [25] and affective factors [18, 26] contribute to adherence behaviour.
The recent COVID-19 pandemic serves as a valuable source of information on adherence practices. A vast amount of research has been dedicated to determining the factors influencing adherence to COVID-19 preventive measures, such as wearing face masks, washing hands, quarantining, and receiving vaccination. The most frequently mentioned factors that influence or are associated with adherence decisions during the pandemic are sociodemographic variables (age, gender, education, etc.), COVID-19-related attitudes and beliefs (including perceived risk of COVID-19), the perceived efficacy of protective behaviour, trust in institutions, and the practical capacity and cost of adherence [23, 27–29]. While these studies reveal important factors influencing adherence, none have addressed the role that embodiment, i.e., one’s own bodily experience, plays in shaping adherence. In this article, we demonstrate that phenomenology can add a novel– embodied perspective on the issue.
While phenomenologists, for the most part, have been reluctant to engage in discussions about adherence to preventive health measures, there are few exceptions. For example, Kattumana and Byrne [30] provide a phenomenological analysis of dissent against large-scale nonpharmaceutical interventions during the COVID-19 pandemic, such as social distancing, large-scale lockdowns and school closures. They claim that Edmund Husserl’s phenomenological discussions concerning the crisis of the sciences can be applied to contestation of public health. With reference to this, they argue that dissent against public health interventions stems from the substitution of population-level reasoning for various context-specific ways of relating to realities that follow large-scale public health interventions (p. 223). In other words, they demonstrate that an individual’s lack of adherence to certain health measures is grounded in the perceived discrepancy between direct experience (negative consequences at the individual/group level) and statistically based public health reasoning (positive consequences at the population level). We find that this work highlights important aspects of nonadherence; however, we believe that phenomenology has more to offer to the discussion. Specifically, we believe that the concept of embodiment, which is central to phenomenology, can help to gain additional insights into individuals’ adherence (or lack thereof) to preventive health measures.
The focus on the embodied perspective in the context of adherence to preventive health measures has already been introduced by De Boer [31] and Rakhra and Grīnfelde [32]. Rakhra and Grīnfelde [32] are interested in embodied motives behind poor adherence practices. More concretely, they focus on embodied motives for poor adherence to oral hygiene regimes, arguing that the difficulty of adhering to health-promoting behaviours and engaging in preventive measures, such as tooth brushing, can be found in one’s experience of bodily absence. The main idea is that in everyday life, when we are healthy, we forget about our bodies; that is, we do not focus on them but instead are engaged in the world through them. Because primary (predisease) prevention involves a presymptomatic bodily state, our body continues to be experientially absent. It can be difficult to remember to wash our hands or to take our vitamins because we tend to forget about our bodies when we are healthy. Therefore, to be successful in adhering to preventive measures, our body needs to become the focus of our attention.3 Because the body itself does not demand our attention in the predisease state, we must rely on other external means of bodily objectification to engage in preventive measures, such as receiving reminders from others or setting them ourselves or being exposed to so-called health-enhancing nudges (e.g., emotionally charged information, such as graphic images on cigarette packs).4 Although de Boer [31] is not interested in embodied (or other) motives for poor adherence, he uses an embodied perspective to analyse the use of concrete preventive health measures (i.e., digital self-tracking applications and digital twins). While he is primarily interested in preventive health behaviour to challenge the dominant concept of health within the phenomenology of medicine, his insights illuminate an important aspect of this behaviour, namely, that it presupposes a focus on one’s body. Thus, with different goals, both Rakhra and Grīnfelde [32] and de Boer [31] note that when preventive measures are not incorporated into one’s habitual body5, they involve a focus on one’s body or bodily objectification. However, neither have focused on the potential role that one’s bodily experience plays in nonadherence. We believe that the concept of the absent body, which is used by Rakhra and Grīnfelde [32] to argue for the embodied motivation for poor adherence, is not applicable to nonadherence.6 This is clearly observed in the case of vaccination—it is very unlikely that vaccine refusal or hesitancy is grounded in the difficulty of remembering to vaccinate.
Our aim in this article is to expand the existing phenomenological research on adherence by adopting an embodied perspective on the much-discussed issue in public why people do or do not adhere to preventive health measures. While adherence can be defined in various ways, it is usually described as either “willingness or unwillingness to follow or comply with recommendations” [35] or “an individual’s behavior aligning with health-related recommendations” [36]. Considering the focus of our phenomenological study, namely, an individual’s experience, we follow the former understanding of adherence.7 Therefore, the question we address why are people willing or unwilling to comply with health-related recommendations? Building on the current phenomenological research [31–32], which shows that when preventive measures are not incorporated into one’s habitual body, they require a focus on one’s body (bodily objectification), we argue that adherence depends on the type of objectification involved—whether it is good or bad objectification, where good objectification involves a focus on one’s body, which is compatible with one’s subjectivity, whereas bad objectification involves a focus on one’s body that disrupts subjectivity. We conclude that from an embodied perspective, nonadherence—understood as unwillingness to comply with health-related recommendations—is grounded in a person’s wish to avoid the disruption of her subjectivity (bad objectification). This will be accomplished by using the results of our phenomenologically grounded study on COVID-19 vaccine hesitancy, in which we focus on both the issue of vaccine hesitancy and adherence to various other preventive measures, such as wearing face masks, maintaining an appropriate distance from other people and washing hands.
We start the article with a short background of our study. We then offer an account of the phenomenological concept of embodiment and the conceptual distinction between good and bad objectification, which is used to ground our empirical study. Afterwards, looking through the lens of the lived body and bodily objectification, we offer an analysis of how adherence to a preventive measure depends on the type of bodily objectification involved. At the end of the article, we consider the potential ways in which the results presented in this article can inform strategies for improving adherence to preventive measures and show how an embodied approach to adherence offers a unique perspective on this issue. We also briefly address potential future research directions within phenomenology in relation to the field of public health.
During the later phases of the COVID-19 pandemic, when infection rates declined and all previously established government restrictions were lifted, we conducted an empirical study on COVID-19 vaccine hesitancy8 from April 2022 until October 2022 using the “Phenomenologically Grounded Qualitative Research” (PGQR) approach [39]. In this approach, concrete phenomenological concepts are used to ground qualitative research, illuminating novel aspects of the experience in question. In our study on COVID-19 vaccine hesitancy, the design of the study, the study’s interview guide and the data analysis were grounded in the phenomenological concept of embodiment. Although the primary focus of our study was on participants’ attitudes towards and experiences of COVID-19 vaccine hesitancy, our dataset included many descriptions of participants’ experiences with other forms of primary disease prevention9 during the COVID-19 pandemic, such as wearing face masks, maintaining an appropriate distance from other people and washing their hands. Considering this, we were interested in determining whether the phenomenologically grounded approach can generate new knowledge not only about the lack of adherence to COVID-19 vaccination but also about the adherence (or lack thereof) to other preventive measures and ultimately to the adherence (or lack thereof) as such. Thus, the aim of this article is not to present the results of our qualitative research regarding COVID-19 vaccine hesitancy.10 Instead, by grounding the interview material in the phenomenological concept of embodiment, we aim to gain new knowledge about the motivational possibilities of adherence to preventive health measures as such.
In doing so, we draw on a phenomenological account of motivation [41, 42], according to which motivation refers to a way in which “worldly objects speak to our body in myriad ways, drawing us into actions, while often remaining only tacitly present in our experience of things” ([43], p. 115). As Husserl ([41], p. 230) points out, we do not experience the world surrounding us “neutrally”; rather, our experience is motivated by the intertwining of other experiences with our bodily dispositions and needs. In line with this, Wrathall ([43], p. 122) characterizes phenomenological motivation as rooted in “the way that our environment and body work together to dispose us to particular ways of acting and experiencing.” In our analysis, both COVID-19 vaccine hesitancy and adherence to preventive health measures as such are not treated simply as products of rational deliberation, but rather as grounded in a pre-reflective, embodied orientation toward the world.
It should be noted however that phenomenologists are interested not only in what is actually experienced, but also—and more importantly—in what can potentially be experienced, or in other words, in experiential possibilities. When we experience something it is always contextualized in other experiences, both present and past, which form the background, expectations and potentialities for it. Because one of the experiential possibilities is the experience of motivation, we can speak of motivational possibilities—that is, of what and how something can be experienced as motivating. In the context of our research, we are interested in identifying the embodied motivational possibilities of adherence to preventive health measures, by which we mean the identification of the pre-reflective bodily orientations that shape participants’ attitudes toward these measures. As our interest is in what and how our embodiment can motivate adherence, we do not, and cannot make any claims about the prevalence of these embodied motivational possibilities in the population.
By embodiment, we refer to the notion found in phenomenological philosophy that rejects Cartesian mind–body dualism, which separates the mind as a psychological existence from the body as a physical existence [13]. According to the phenomenological approach, the mind is embodied, and the body is minded, and this embodied existence of the human being is expressed through the concept of the lived body (Leib) [41]. The lived body expresses the experiential unity between the self, the body and the world. Focusing on the unity between the self and the body, the phenomenologist Maurice Merleau-Ponty ([42], p. 151) states that there is no experiential distance between myself and my “I am not in front of my body, I am in my body, or rather I am my body.” To characterize this fundamental unity between the body and the self, Kay Toombs ([44], p. 90) uses the concept of bodily wholeness. Focusing on the experiential unity between the self, the body and the world, Merleau-Ponty refers to the concept of motor or original intentionality. He writes, “Consciousness is originarily not an ‘I think that’ but rather an ‘I can’” ([42], p. 84). Through our lived body (through walking, speaking, catching, etc.), we are directed towards various projects in the world (e.g., the destination of our walk, the content of our speech or the ball we try to catch). When involvement in the world is smooth (without any disturbances), one experiences a sense of bodily certainty, which refers to the subtle feeling of ‘I can’ that pervades our actions in normal circumstances ([45], p. 87). In normal circumstances,11 I have tacit confidence that I will be able to walk down the stairs, finish my dinner or write a note. According to Carel, this tacit sense of confidence is “a basic mode of action that takes agency for granted” ([45], p. 91). The lived body thus also expresses the sense of agency, which includes both the sense of ‘I can’ and the sense of myself as an author of the action in question [46].
Additionally, when we are involved in the world, the lived body remains experientially absent. As Leder ([47], p. 1) points out,[w]hile in one sense the body is the most abiding and inescapable presence in our lives, it is also essentially characterized by absence. That is, one’s own body is rarely the thematic object of experience.
When we are walking, talking or doing any other activity, we usually do not pay attention to our bodies. These actions have become automatic, or, to use a concept from Merleau-Ponty’s phenomenology [42], they have been incorporated into one’s habitual body. Phenomenologists of medicine have referred to this absence of the habitual lived body to characterize the experience of health [43–44, 46]. According to Carel ([45], p. 55), “The fundamental bodily experience of health is one of harmony, control, and predictability”. In summary, the lived body is not a passive object but rather an active centre of our experiences that is expressed through the associated concepts of bodily wholeness, bodily certainty, bodily agency and bodily absence.
Although phenomenologists interested in applying phenomenology to health care have been critical of the dominant view within medical practice of the body as a material thing, they recognize that we can and often do adopt an objectifying view of our bodies (or their parts), especially when we are ill [44–45, 47]. Adopting an objectifying view of one’s body or objectifying one’s body presupposes an awareness of one’s body. This awareness of one’s body can be brought about by different things, such as my own will (I decide to inspect my eye, for example), the body itself (through various feelings and sensations) and the internalized gaze of the other [44, 47].
While there are various ways of categorizing types of bodily objectification or bodily self-awareness [47–49] in the context of this article, we focus on the recent distinction introduced by Svenaeus [50] between two types of bodily good and bad objectification. According to Svenaeus ([50], p. 142), the type of objectification, which involves the awareness of oneself as an object without disrupting aspects of one’s lived body other than its absence (such as bodily agency, wholeness and certainty), is called ‘good objectification.’ An example of this type of objectification is the admiration of oneself in the mirror. While this activity presupposes an awareness of one’s body, it can be compatible with the sense of oneself as an agent of the action (bodily agency), with confidence in one’s bodily possibilities (bodily certainty) and with the sense of unity between oneself and one’s body (bodily wholeness). In other words, it is compatible with one’s subjectivity. In contrast, the type of objectification that involves the awareness of oneself as an object in a way that disrupts one’s lived body is called ‘bad objectification.’12 The latter includes the disruption of one’s bodily wholeness (evoking bodily alienation), bodily certainty (evoking bodily doubt)13 and bodily agency (evoking the loss of control). The experience of bad objectification thus disrupts one’s subjectivity.
We conducted 16 semistructured interviews with adult participants in Latvia who identified themselves as COVID-19 vaccine hesitant. The sample included 10 people who had not received the COVID-19 vaccine at the time of the interview and 6 people who had received at least one dose of COVID-19 vaccine at the time of the interview. Among the latter group, 4 people (Hannah, Sandra, Theodor and Elisabeth) complied with the mandatory vaccination issued by the government14, whereas the remaining 2 (Matthew and Martin) received the first dose of the COVID-19 vaccine voluntarily, but were hesitant towards receiving subsequent doses. Four of our research participants had not received any type of immunization as adults (Theodor15, Thomas, Maria and Anna), whereas the remaining twelve were hesitant specifically about receiving the COVID-19 vaccine (Table 1).
Table 1Participants’ vaccination statusPseudonymCovid-19 vaccine receivedOther vaccines receivedThomasnonoHannahyes (forced)yesOlafnoyesTheodoryes (forced)noVictornoyesMarianonoMartinyes (voluntary)yesSandrayes (forced)yesElisabethyes (forced)yesMatildanoyesMatthewyes (voluntary)yesOscarnoyesGeorgenoyesGretanoyesAnnanonoVeranoyesIf a participant received the COVID-19 vaccine unwillingly due to the mandatory vaccination issued by the government, it is referred to as forced
We used purposive and snowball sampling techniques to select our research participants. The inclusion criteria were adults 18 ≥ years of age, Latvian speaking, male and female, all ethnic and racial groups, and identifying as vaccine hesitant. Of the 16 participants, 8 were women and 8 were men, and they ranged in age from 25 to 85 years (median 44) (Table 2). We recruited participants by contacting the gatekeepers of communities with a high number of vaccine-hesitant members, such as senior care facilities, through social media platforms and by applying a snowball approach within the social network of the researchers involved in this project. Informed consent was discussed with and obtained in written form from all participants at the beginning of each interview by one of the authors of this article, and all the data used in this study and elsewhere were anonymized.
Table 2Participants’ demographicsPseudonymGenderAgePlace of livingLevel of educationAverage monthly income (in €)Marital statusThomasM25ruralVocational Secondary Education< 889Married or living with a partnerHannahF46urbanVocational Secondary EducationDifficult to sayMarried or living with a partnerOlafM31ruralHigher education (University)from 594–889Married or living with a partnerTheodorM25urbanVocational Secondary Education< 889Married or living with a partnerVictorM38urbanHigher education (University)< 889SingleMariaF54urbanVocational Secondary Educationfrom 427–594Married or living with a partnerMartinM52urbanHigher education (University)from 427–594Married or living with a partnerSandraF46urbanHigher education (University)from 594–889Married or living with a partnerElisabethF64urbanHigher education (University)from 427–594DivorcedMatildaF54urbanHigher education (University)< 889Married or living with a partnerMatthewM33urbanHigher education (University)from 312–427Married or living with a partnerOscarM38urbanHigher education (University)< 889SingleGeorgeM38urbanHigher education (University)< 889SingleGretaF85urbanVocational Secondary Educationfrom 312–427DivorcedAnnaF52ruralHigher education (University)< 889Married or living with a partnerVeraF28urbanHigher education (University)< 889Single Income brackets were self-reported by participants
We relied on the PGQR approach [39] by using core phenomenological concepts in designing the interview guide, conducting interviews and analysing the data with the aim of identifying the embodied motivational possibilities of COVID-19 vaccine hesitancy. We used the concept of embodiment to develop our interview guide (Table 3). In light of the topic of our research, namely, vaccine hesitancy, which is a complex and context-specific phenomenon [52], the focus of our research was not on an isolated experience of vaccine hesitancy but rather on the vaccine-hesitant individual’s embodied and situated being in the world as a whole. Because of this, the interviews contained much information regarding vaccine-hesitant individual’s embodied being in the pandemic world, including their attitudes (feelings, cognitions and behaviours) towards other preventive measures, such as wearing face masks, maintaining an appropriate distance from other people and washing their hands.
Table 3Interview guideTopicQuestionsPerson’s affective being in the pandemic world1. How did you feel at the beginning of the pandemic until the vaccine became available?2. How did you feel after the availability of the vaccine?3. What were your emotions when restrictions for the unvaccinated began?4. What emotions did you feel when thinking about vaccination?Person’s embodied being in the pandemic world1. How, if at all, your life changed during the pandemic [work life, family life, hobbies, shopping, receiving health care, communication with others]?2. How, if at all, your life changed after choosing not to vaccinate?3. How did you react/act towards other measures to fight the pandemic (distancing, masks)?4. What benefits, if any, you have gained from the pandemic?Being with others during the pandemic1. How did you experience the attitude of other people/health professionals/government?2. How did other people (institutions) treat you?3. How did you treat other people (vaccinated / unvaccinated)?Person’s feelings and actions toward the process of COVID-19 vaccination and the vaccine itself1. How do you feel when thinking about COVID-19 vaccination? Other vaccines?2. What did you do (if anything) to avoid getting COVID-19?3. Have you ever gotten any type of vaccine? If yes, what was your experience?4. Why have you not vaccinated against COVID-19 yet?5. Imagine you have gotten the COVID-19 vaccine– what do you think has happend to you? What changes have occured in your body?Person’s relationships with her own body in terms of health, illness and everyday life1. How do you feel/what do you do when you are healthy?2. How do you feel/what do you do when you are sick?3. [if applicable] How did you experience being sick with COVID-19?4. How do you take care of your body daily?
The interview process itself was largely inspired by the framework developed by Høffding and Martiny ([53], p. 558), who maintain that “in the interview process one should be aware of one’s phenomenological commitments, take up an empathetic, reciprocal and second-person perspective when encountering the subject, and ask specific open questions in order to get descriptions that are as detailed as possible”. Additionally, the goal of the interviews was to cogenerate descriptions of experiences that did “not pop up in the typical and oft-rehearsed self-narratives” of the interviewees ([39], p. 160), that is, the interviewer aimed to evoke descriptions of prereflective experiences. With respect to the pragmatics of the interviews, phenomenological interviews share many similarities with in depth, open-ended interviews (using open-ended “how” questions, for example); however, they also involve phenomenological grounding in the form of the phenomenological sensitivity of the interviewer ([39], p. 160). The phenomenological background of the interviewer allows her to recognize the need to modify the interview guide to obtain the relevant data and to introduce phenomenologically informed follow-up questions during the interview on the basis of the participants’ descriptions of their experiences. Thus, during the interview process, there was an ongoing implicit phenomenological analysis occurring of which answers could be used for the development of phenomenological themes, what kind of phenomenological concepts they involve, if they contradict one another, etc ([53]., p. 556). Overall, when conducting the phenomenological interview, we—as interviewers—did not enter the interview as neutral parties. We had a conceptual lens, which helped us cogenerate interviewees’ descriptions. However, this conceptual lens itself was open to modification on the basis of interviewees’ descriptions.
For the data analysis, the material was first analysed using inductive thematic analysis [54], which involved coding the transcribed data and identifying themes and subthemes using NVivo 12 plus software. This was necessary to remain open to changes in the selection of the predefined phenomenological concepts, leading to the next step of the analysis, which entailed rereading and recoding the data in light of the relevant phenomenological concepts and discussions about these concepts in the phenomenological literature. We used various phenomenological concepts to analyse vaccine hesitancy, i.e., the lived body and the object body, collective body memory, bodily certainty, intersubjective and bodily normality and the life-world. This resulted in regrouping codes and subthemes into phenomenologically cantered codes and phenomenological themes, which expressed motivational possibilities of COVID-19 vaccine hesitancy, such as, for example, the “fear of losing one’s lived body”. Although not the initial aim of our research on COVID-19 vaccine hesitancy, we continued investigating embodied motivational possibilities with respect to other types of preventive measures present in the interview material to determine whether the previously identified motivational theme, namely, “the fear of losing one’s lived body” (evoked by bad objectification), was present in participants’ experiences of other preventive measures. As we will argue in the following, it is not.
To enhance reliability, all authors of this article were involved in the coding process; each of the three authors conducted the coding process separately, and then, through discussions among the coauthors, emerging themes were identified and referred back to the individual transcripts to ascertain that all significant aspects were captured. The final phenomenologically grounded analysis was discussed among the authors until all authors reached a consensus. To ensure the intersubjective validation of the research findings [53], drafts of the analysis process were presented at various phenomenological conferences and seminars, leading to several reinterpretations of the arguments presented in this paper.
In what follows, we examine our study participants’ attitudes towards preventive health measures during the pandemic through the lens of good and bad bodily objectification. We will show that in cases when preventive measures are not incorporated into one’s habitual body, adherence—understood as willingness or unwillingness to comply with health-related recommendations—depends on the type of objectification involved—whether it is good or bad objectification. We will start by looking at COVID-19 vaccine hesitancy.
Vaccination as a preventive measure involves a focus on one’s body or bodily objectification. This focus, however, is usually of short duration—during the administration of an injection of vaccine and, in some cases, during a short period afterwards if there are side effects (such as a sore arm, headache, or temperature). In many instances, the objectification involved in vaccination does not threaten to disrupt one’s sense of bodily certainty, wholeness or agency; that is, it is a form of good objectification. One does not necessarily feel alienated from one’s body or lose the sense of trust in one’s body owing to the short-term bodily awareness involved in vaccination. Moreover, bodily awareness evoked by preventive practice is sometimes compatible with increased experiential possibilities of one’s lived body. Most of our research participants not only did not anticipate or experience the disruption of their lived bodies after receiving other vaccines (such as a vaccine against tick-borne encephalitis) but also anticipated an increase in their sense of agency in the form of, for example, being able to perform activities in the woods. In some cases, however, the objectification (or the anticipated objectification) involved in vaccination threatens to disrupt one’s lived body; that is, it is a form of bad objectification. On the basis of the interview data, we argue that for several of our participants, COVID-19 vaccine hesitancy was grounded in anticipated disruption of their lived bodies due to the objectification brought about by the event of vaccination, i.e., due to the bad objectification. As we have made a more extensive argument for this elsewhere16, in what follows, we provide a brief overview of our argument.
Two of our research participants (Thomas and Matilda) talked about anticipating increased awareness of their bodies after COVID-19 vaccination. For example, when asked to imagine what would happen to him if he received the COVID-19 vaccine, Thomas said that he would start paying more attention to his body, monitoring every unusual sensation. Another participant, Matilda, noted that if she received the COVID-19 vaccine, she would start to constantly think about every bodily sensation and feeling she has. Both Thomas and Matilda described anticipating increased focus on their bodies—a focus that would not be by their choice and that they would not want to experience. For both Thomas and Matilda, the objectification that they anticipate to occur after the COVID-19 vaccination is unwelcome precisely because it poses a threat to their lived bodies—they would not be the ones choosing to focus on their bodies (their sense of bodily agency would be disrupted), and they would no longer have a sense of trust in their bodies (their sense of bodily certainty would be disrupted). Thus, it is possible that their COVID-19 vaccine hesitancy is grounded in the wish to avoid disruption of their lived bodies (bad objectification), which they anticipate to occur after COVID-19 vaccination.
As our study also included participants who had already received (some of them unwillingly due to the governmental policy of mandatory vaccination) the COVID-19 vaccine at the time of their interview, we observed that some of them had experienced disruption of their lived bodies (bad objectification) after vaccination, which motivated their hesitancy regarding revaccination. While for some people unwelcome focus on their bodies after vaccination is present in the first few days due to the side effects of the vaccine, such as headaches, high temperature, and fatigue, importantly, for all of our participants who had received the COVID-19 vaccine (Hannah, Martin, Sandra, Matthew, Martin, Theodor), it continued to be present after the initial side effects disappeared. They talked about monitoring new, prolonged and unwelcome symptoms (such as ruptured blood vessels, bruising over the whole body, hypersensitivity to cold (Hannah), severe exhaustion, issues with memory, inability to concentrate, and heart and joint problems (Martin), premature menopause, pain in the joints, swollen lymph nodes, heart and lung problems (Sandra), severe headache (Matthew), and constant exhaustion (Theodor)) that they suspected were side effects of the COVID-19 vaccine. Importantly, these unwelcome experiences had a negative influence not only on their physical bodies but also on their lived bodies. Several phenomenologists [44, 47, 55] have noted that pain and illness have an impact not only on one’s physical body but also on one’s lived body. Toombs ([44], p. 62) illustrates this with reference to experiencing “A headache is not experienced simply as a pain in the head, but as the “inability to” concentrate on the book I am reading, enjoy the music I am listening to, have an animated conversation with my spouse, and so forth”. The interview material supports this. The aforementioned unwelcome physical sensations that occurred after the COVID-19 vaccination for our research participants had a negative influence on their lived bodies. For example, the hypersensitivity to cold that Hannah experienced after vaccination had a negative influence on her sense of agency, as she was no longer able to swim in cold water. Martin’s heart problems negatively influenced his sense of bodily agency, as he was no longer able to walk his dog and be productive at work. Sandra’s premature menopause evoked a sense of bodily doubt, as she was no longer able to rely on her body to function the way it did before, and a sense of bodily alienation, as she no longer experienced a sense of unity with her body.
Martin’s description of his experience of extreme exhaustion after vaccination illustrates the disruption of his lived “I have a feeling that if I start doing intellectual work, I will soon experience extreme exhaustion and a light, throbbing headache. This makes me afraid, so I start avoiding the intellectual work I’m used to doing—my job [.. ]”. Martin’s fear of engaging in the usual habitual activities after the vaccination illustrates that he has lost his sense of bodily certainty and bodily agency. He can no longer rely on the tacit, habitual functioning of his body, his “I can”. Instead, he has started to doubt it. Martin’s experience demonstrates that his exhaustion (which is a physical symptom) has an impact on his lived body.
Sandra’s vivid description of her experience after vaccination provides another example of the disruption of the lived body after My back hurts, my joints ache; in the morning, when I get up, my ankles and feet hurt, and I no longer can play [an instrument] because I have lost my coordination to some extent, and it bothers me a lot [.. ]. I am afraid that I won’t be able to get myself back in the active form, which I had two years ago [..]
This quotation illustrates that after vaccination, both Sandra’s physical body and her lived body were disrupted. Regarding the disruption of her lived body, vaccination has evoked the loss of her bodily absence (expressed through the monitoring of unwanted bodily sensations and feelings), the disruption of her sense of bodily agency (expressed through her inability to play the instrument) and the loss of her bodily certainty (expressed in the form of ‘I no longer can’ and, most importantly, in the form of ‘I may never be able to’).
These accounts of participants’ experiences after initial COVID-19 vaccination illustrate that their past experiences, which disrupted both their physical and lived bodies, motivate their reluctance to revaccinate. All participants who had already received the COVID-19 vaccine at the time of their interview explicitly linked their post-vaccination experiences with their reluctance to undergo further vaccination. For them, this reluctance was grounded in a fear of experiencing bad objectification again, as they had after their initial vaccination.
We conclude that from an embodied perspective, COVID-19 vaccine hesitancy is grounded in anticipated disruption of one’s lived body due to the objectification brought about by the event of vaccination, i.e., due to bad objectification.
While the participants in our study were hesitant to receive the COVID-19 vaccine, most of them did not hesitate to engage in various other health-promoting and preventive measures suggested by epidemiologists and health care professionals, which, in some cases, were enforced by the government (Table 4).
Table 4Other COVID-19 prevention measures usedPseudonymOther COVID-19 prevention measures usedThomasFace masks, social distancing, staying at home during lockdownHannahStaying at home during lockdown and all of the other measuresOlafFace masks, social distancing, use of surgical gloves, staying at home during lockdownTheodorFace masks, handwashing, staying at home during lockdownVictorFace masks, hand and surface disinfectionMariaStaying at home during lockdownMartinStaying at home during lockdownSandraFace masks, handwashing, hand and surface disinfection, staying at home during lockdownElisabethFace masks, handwashing, social distancing, use of surgical gloves, taking vitaminsMatildaFace masks, taking vitamins, staying at home during lockdownMatthewFace masks, social distancingOscarFace masks, social distancing, use of surgical gloves, staying at home during lockdownGeorgeStaying at home during lockdownGretaFace masks, handwashing, social distancing, hand and surface disinfection, staying at home during lockdownAnnaHand and surface disinfection, taking vitaminsVeraStaying at home during lockdown
In describing their experiences during the COVID-19 pandemic, participants mentioned willingly complying with recommended health measures such as wearing face masks (Olaf, Theodor, Greta, Victor, Sandra, Elisabeth, Thomas, Matilda, Matthew, Oscar), washing their hands regularly (Theodor, Greta, Sandra, Elisabeth), disinfecting their hands and various surfaces (Greta, Victor, Anna, Sandra), maintaining distance from others (Olaf, Elisabeth, Thomas, Matthew, Oscar), wearing surgical gloves (Olaf, Elisabeth, Oscar), taking vitamins (Matilda, Elisabeth, Anna), and staying at home during quarantine periods (Thomas, Theodor, Olaf, Greta, Maria, Hannah, Matilda, Vera). Greta’s description of her attitude towards preventive measures during the pandemic illustrates the overall sentiment of our research I observed all the preventive measures required except vaccination. I did not walk around without a strong reason, I wore a face mask when I went to the shop, I washed my hands, I disinfected my hands, I maintained 2 m of distance [from others] [..]
Why did our research participants were willing to comply with these health measures? We conjecture that a conceptual framework of good and bad objectification can provide a possible explanation for this. First, we assume that at least some of these cases of complying with preventive health measures involved bodily awareness. This is supported by phenomenological studies that show that the pandemic and the countermeasures it involved increased awareness of one’s body [56–58]. Because of the fear of infection, the vast amount of information provided daily, and governmental policies, one’s own body was at the forefront of attention for most people, especially at the beginning of the pandemic. Additionally, some of our participants described actually experiencing bodily objectification while engaging in preventive health practices. For both Sandra and Greta, wearing face masks evoked an unwanted focus on parts of their bodies—for Sandra, owing to having glasses, and for Greta, because of difficulty breathing. Sandra described this in the following Physically, it was difficult for me because I have glasses, and it was physically difficult during winter to wear face masks because my vison was constantly obscured because my glasses fogged up. And it was physically difficult, but I was not annoyed by it, even privately [.] I just accepted that I must do it and that’s it.
From the embodied perspective, wearing face masks evoked bodily awareness (objectification) and, with it, the loss of her bodily absence. She was, however, willing to comply with this health measure.
Second, we conjecture that the bodily objectification involved in the aforementioned preventive health practice did not threaten our participants’ lived bodies, i.e., that it was good objectification. While these practices could and did disrupt the sense of their bodily absence (which is one characteristic of the lived body), namely, they experienced heightened bodily awareness, the participants did not experience a threat to their sense of bodily wholeness (i.e., they did not experience alienation from their bodies), a threat to their sense of bodily certainty (i.e., they did not lose confidence in their bodily abilities) or a threat to their sense of bodily agency (i.e., they did not lose the sense of themselves as agents of their own experiences). In the previously given quotation by Sandra, we can see that despite the loss of her bodily absence, Sandra was willing to comply with this recommendation and continued to wear face masks. We conclude that adherence to preventive measures, which involves bodily objectification, involves the type of good objectification. We do not, however, claim that good objectification is sufficient for adherence, as studies point to various other factors influencing adherence, such as perceived benefits and threat appraisal [23–24], efficacy beliefs [19, 22], risk assessment [23] and trust in institutions (19–20, 23].
Notably, there are various reasons for perceiving a preventive measure as threatening (or not threatening) to one’s lived body, the analysis of which exceeds the scope of this article. Some of these factors include individuals’ embodied history (previous experiences with preventive measures as well as the level of trust in one’s body), the experience of other people (especially the experiences of family members and friends after receiving vaccines), the invasiveness of preventive measures (whether they involve alterations within one’s body), and the sociopolitical context (governmental mandates regarding preventive measures as well as the general attitudes of family members and friends towards them). To illustrate one factor—the invasiveness of preventive measures—two of our research participants (Sandra and Olaf) explicitly compared the COVID-19 vaccine with other preventive measures, stating that the COVID-19 vaccine has a greater impact on their bodies than do preventive measures such as wearing a face mask, for example. Sandra described the COVID-19 vaccine as impacting her internally, saying that “it has a direct impact on her spine and blood circulation”, whereas other preventive measures were perceived by her as having only an external impact on the body. This finding supports the claim made by several phenomenologists that the disruption of one’s physical body is also a disruption of one’s lived body [44, 47, 55]. In light of this, it is possible to conjecture that nonadherence is grounded in one’s wish to avoid the disruption of not only one’s physical body but also one’s lived body or subjectivity.
An embodied perspective on adherence to preventive health measures introduced in this article can be useful in thinking about strategies for improving adherence to preventive measures in the community. Although we do not deny the importance of existing strategies for improving adherence to preventive measures, such as risk communication, health education, financial support and access to essential supplies and services [59], we suggest that an embodied perspective can offer a new perspective. From an embodied perspective, for a preventative measure to work,—i.e., for a person to be willing to comply with a health recommendation—, it must involve a form of good objectification; that is, a person must both focus on her body and retain the sense of her subjectivity. This is in line with previous work that has evaluated strategies for increasing adherence. As an example, the argument proposed by Schramme [60] that health-enhancing nudges can be bad for people’s health because they assume inferior agency in their targets is in line with the embodied perspective on the issue presented in this article, namely, that health-enhancing nudges fail because (due to the evoked bad objectification) they threaten to disrupt one’s lived body or subjectivity. Moreover, the idea that successful adherence must involve a form of good objectification, meaning that it has to strengthen (among other things) an individual’s sense of agency, is in line with the World Health Organization’s call for health promotion to empower individuals [61] and is supported by the insight found in the literature that a key to successful adherence is individual empowerment [62].
Additionally, one’s lived body is shaped by the social context and can also be disrupted by it. This insight is in line with research findings showing that adherence to preventive measures depends on various social factors [59]. The embodied perspective on adherence to preventive health measures highlights the importance of social factors in determining adherence. As an example, we suggest that governmental policies for preventive measures that threaten individuals’ sense of subjectivity tend to decrease willingness to comply with these measures. It follows that these strategies should consider their impact on individuals’ sense of subjectivity. This involves reevaluating existing governmental policies regarding preventive measures while considering their potential harm to individuals’ sense of subjectivity and changing them if necessary. Alternatively, it involves the development of policies that strengthen individuals’ sense of subjectivity, such as inclusive policy making, which involves individuals in the health policy-making process (through focus groups, public forums, etc.), and transparent policy making, which builds trust within the community. By offering an understanding of what is important to the individual (from the perspective of the individual herself) regarding prevention, an embodied perspective on adherence to preventive health measures can potentially inform the development of health communication strategies.
While the results presented in this article offer some preliminary insights regarding strategies to increase willingness to comply with health-related recommendations, we also want to discuss previously neglected but promising future research directions within the phenomenology of health. The phenomenological tradition has more value in addressing issues relevant to the field of public health than could be presented in this article, such as concepts of the life-world, motivation, sedimentation and the habitual body [42, 63–64] as well as concepts of community feelings and we-intentionality [65–67]. While the former cluster of concepts can be useful in addressing issues connected to the health motivation and health behaviour of an individual (including the rethinking of the concept of ‘health behaviour’ itself), the latter cluster can potentially be helpful in addressing group experiences.
Additionally, the embodied perspective on adherence to preventive health measures offered in this article puts pressure on the dominant concept of health as a state of transparency within the phenomenology of medicine. While the dominant view conceptualizes health with reference to the absent body [44–45, 68], on the basis of the results of our study, we claim that the experience of health is compatible with the experience of good objectification. In other words, the focus on one’s body, which is a necessary part of prevention, does not threaten one’s experience of health. Moreover, it highlights the understanding of health as a dynamic process (instead of a harmonious state) that involves the interplay between the presence and absence of one’s body.
In our analysis, we relied on the phenomenological insight that the lived body is shaped by the sociopolitical context and that this context can play a significant role in evoking the experience of bad objectification. Taking this into account, from the embodied perspective, adherence to preventive measures encompasses both individual and social dimensions. This opens the possibility of combining a phenomenological approach to adherence understood as willingness or unwillingness to comply with health-related recommendations (which starts from the analysis of an individual’s experience through qualitative in-depth interviews) with other methodological approaches (such as surveys and questionnaires) that aim to examine patterns of compliance with health-related recommendations across specific population groups. Further research is needed to establish the potential usefulness and practical applicability of the phenomenological approach in researching the patterns of compliance with public health advice across specific population groups. Finally, further research that focuses on the complex relationship between the embodied motives for adherence to preventive measures and the established determinants of adherence, such as health cognitions, socioeconomic status, and age, is needed [16, 21, 59]. We conjecture that the embodied motives behind willingness or unwillingness to comply with health-related recommendations are shaped by and shape various established determinants of adherence.
Finally, the study has several limitations. First, the results of this study are based on data gathered during the COVID-19 pandemic. Further research is needed to determine whether the same conclusions regarding the embodied motives for unwillingness to comply with health-related recommendations apply to normal, nonpandemic circumstances. Second, the data were gathered under specific sociopolitical circumstances, which were demonstrated to influence participants’ adherence practices,—for example, receiving vaccination unwillingly due to governmental policies. Further research is needed to determine whether the same conclusions apply to other circumstances. Third, the generalizability of this study is limited for reasons pertaining to sample size, sample coverage and volunteer bias. With respect to sample coverage, people living in a city and having higher education levels were overrepresented. While we suspect that the place of living and the level of education do not influence the results regarding the embodied motives for adherence, a more diverse sample would be needed to be certain of this. However, importantly, the findings of this type of phenomenologically grounded research are not intended to be generalized to the population. The aim of this study is to generate knowledge about the motivational possibility of adherence to preventive health measures without making any claims concerning its prevalence among the population. In the future, it would be fruitful to consider the possibility of performing phenomenological mixed method studies by combining qualitative and quantitative methods with the aim of obtaining a richer understanding of the issue in question [69]. Finally, the phenomenological perspective on adherence in this article is limited to an understanding of adherence as “willingness or unwillingness to comply with preventive measures”. While willingness to comply with preventive health measures can—and indeed often does, as evidenced by the interview material—translate into behaviour, this is not always the case. Behavioural adherence to preventive health measures depends on factors outside an individual’s lived experience, such as political context and economic conditions. Studies [30] have shown that due to their socioeconomic circumstances, people may face structural barriers that prevent them from following COVID-19 control measures, even if they are willing to comply. Likewise, our interview material showed that an individual may be unwilling to comply with a preventive measure, yet still do so due to external pressures such as mandatory vaccination policies. Further research is needed to explore how willingness or unwillingness to comply with preventive health measures interacts with external structural factors, such as socioeconomic conditions and policy mandates, in shaping behavioural adherence.
In this article, we introduced an embodied perspective on adherence to preventive health measures—understood as willingness or unwillingness to comply with health-related recommendations—, which has thus far been neglected in discussions about adherence. We relied on the current research within contemporary phenomenology, which shows that when preventive measures are not incorporated into one’s habitual body, they involve bodily objectification, and we argued that whether someone is willing to comply with a preventive measure depends on the type of bodily objectification involved, i.e., whether it is good or bad objectification. Referring to both existing theoretical research and interview data, we argued that willingness to comply with a preventive measure involves good objectification, whereas unwillingness to comply with a preventive measure is grounded in anticipated bad objectification or a person’s wish to avoid the disruption of her subjectivity. Importantly, we do not claim that good objectification is sufficient for adherence, as studies point to various other factors influencing adherence. Additionally, we do not claim that certain types of preventive measures (e.g., wearing face masks) always involve good objectification versus other types (e.g., vaccination) that always involve bad objectification. Instead, we claim that in cases when preventive measures are not incorporated into one’s habitual body, nonadherence or unwillingness to comply with these measures involves bad objectification (a focus on one’s body that disrupts one’s subjectivity), and adherence or willingness to comply with them involves good objectification (a focus on one’s body that does not disrupt one’s subjectivity).17 By recognizing this embodied motivational orientation toward preventive health measures, we offer an additional perspective on the complex issue of the motivation behind adherence.