https://orcid.org/0000-0002-2118-4174
ABSTRACT
Despite the availability of school-based immunization programs (SBIPs) in Canada, human papillomavirus (HPV) vaccine uptake remains suboptimal. Vaccine education may improve vaccine uptake among adolescents. The objective of this qualitative study was to identify opportunities for HPV vaccine education in British Columbia, Canada, by exploring the perspectives of students, parents, school staff, and public health nurses on the current SBIP. Individual semi-structured interviews were conducted with adult participants and focus groups were conducted with grade 6 students between November 2019 and May 2020. The interviews and focus groups were transcribed and then analyzed using reflexive thematic analysis. Opportunities for HPV vaccine education were identified in three themes: 1) making SBIPs student-centered; 2) adopting a collaborative and interdisciplinary approach to vaccine education; and 3) actualizing parent education opportunities. Broad support existed for a formal, collaborative HPV grade 6 vaccine curriculum delivered by teachers and public health nurses to provide evidence-based health information. Participants voiced that the curriculum should integrate students’ perspectives on topics of interest and address needle associated pain and anxiety. Parents were identified as the primary vaccine decisionmakers, therefore, participants stated it was crucial to also provide parent-directed vaccine education as part of SBIP. Our findings support the development of a collaborative HPV vaccine curriculum directed to and informed by students and parents to buttress current SBIPs in British Columbia.
Introduction
The human papillomavirus (HPV) vaccine is an effective means of primary prevention for HPV-associated diseases, particularly when delivered in early adolescence.Citation1–3 HPV vaccination efforts have been scaled-up across Canada through publicly funded, school-based immunization programs (SBIPs), first being offered to girls in 2008 and boys in 2017. In British Columbia (BC), vaccination programs are delivered through five regional health authorities and the First Nations Health Authority. Adolescents in grade 6 (11 or 12 years of age) and grade 9 (14 or 15 years of age) have the option of receiving the HPV vaccine through SBIP delivered by public health nurses or in a local health unit, medical office or pharmacy. Despite the widespread availability and effectiveness of the HPV vaccine, uptake remains far below the 90% coverage goal for grade 6 students, with 2019 2-dose coverage ranging from 60.5 to 70.3 depending on the school authority.Citation4 Disruptions from the COVID-19 pandemic further impacted vaccine coverage due to school closures and interruptions in SBIPs.Citation4
SBIP are an effective and cost-efficient approach to improve vaccine uptake among adolescents by improving the convenience of vaccination.Citation5 However, not all SBIP incorporate vaccine education as a supplementary strategy to improve vaccine knowledge. Educational school-based interventions, such as vaccine education, may be effective for improving adolescent HPV vaccine uptake, vaccine confidence, self-efficacy, and decreasing vaccine-related anxiety, particularly among populations with previous low vaccine uptake.Citation6–10 School-based interventions have also been found to increase adolescent knowledge about HPV prevention and boost preventative behaviors around sexually transmitted infections.Citation11,Citation12
Despite evidence of the effectiveness of vaccine education for improving vaccine uptake among adolescents, HPV specific or general vaccine education is not formally included in the current grade 6 BC school curriculum. The absence of vaccine education may be a missed opportunity considering that adolescents receive the HPV vaccine at this age in SBIP. Importantly, the current literature on HPV SBIPs and vaccine education lacks the perspectives of students.Citation13 The objective of this qualitative study was to identify opportunities for HPV vaccine education in BC SBIPs by exploring the perspectives of students, parents, school staff, and public health nurses on current SBIPs.
Materials and methods
Setting and recruitment
This study was part of a larger research project examining determinants of HPV vaccine uptake in Canada.Citation14,Citation15 The study was conducted in collaboration with regional health authorities,’ local school boards, medical health officers and nurses responsible for planning of SBIPs.
Mindful of the interplay between researchers’ backgrounds on study design, data collection and analysis, two of the researchers are health care providers with qualitative research expertise. This professional background may cause them to focus on individual, person-to-person interactions, such as the interplay between select nurses/teachers/parents and students, and the clinical interaction of the vaccine-day experience. The other three researchers have public health expertise and may be more cognizant of the systems level and policy-based decisions that define vaccine education and SBIPs.
Participating school boards were selected using purposive sampling in order to include participants from large, medium and small-size communities from 3 of the 5 regional BC health authorities. Sample size was not decided a priori. Recruitment of students and parents was curtailed due to pandemic related school closures in spring 2020. Eligibility criteria were the following for each participating school: grade six student, parent/caretaker of a grade six student, grade six teacher, primary school principal or the public health nurse at a participating school; English speaking; and ability to participate in an in-person or virtual interview or focus group (students). Students and their parents were not paired, meaning that either student or parent or both could participate in the study. Participants provided written consent (adults) or written assent (adolescents) before the interview or focus group and were provided a gift card upon completion.
The study invitation was extended to local school boards who then identified interested school principals. Recruitment was done at schools where the principal indicated an interest in participating and consented to an interview. Principals disseminated the study invitation to all grade six teachers, parents and students at the school. Study information was also included in the participating schools’ newsletters. Public health nurses providing vaccinations at the selected schools were invited to participate. Since study participants were contacted through their schools, we were unable to track individuals who declined to participate.
Data collection
We developed a semi-structured focus group discussion guide for students and separate semi-structured interview guides for parents, teachers, principals and nurses. Focus groups for students were chosen over individual interviews for pragmatic reasons. We agreed that many Grade 6 would be uncomfortable with individual interviews but would be open to participate in a group discussion with their peers. As earlier research supports, focus groups also provided an opportunity to observe interactions between participants and generate a broader range of perspectives.Citation16
Focus group and interview guides were based on the sensitizing concepts of the study and review of literature examining experiences with SBIPs and HPV vaccination.Citation13,Citation15,Citation17 Background information was obtained from consultations with regional health authority medical health officers and nurses responsible for planning grade six vaccine programs, review of relevant documents (SBIP consent forms, vaccine information sheets) and observations of SBIPs days at several nonparticipating schools. We explored the attitudes and perceptions about vaccines in general and HPV vaccination specifically, SBIP, and potential opportunities to increase HPV vaccine uptake. Discussion guides were pilot tested with 2 students and 2 parents who were not at participating schools.
All interviews with adults were conducted either in-person or by phone by research staff who had no relationship with the participants. Five student focus groups were conducted by research staff in-person at the participating schools and two student focus groups were conducted virtually, due to COVID-19 pandemic restrictions. Participants were informed about their interviewers’ background in clinical care or public health. All interviews and focus groups were audio recorded and transcribed verbatim by a professional transcriptionist. Transcripts were deidentified and accuracy was checked by a member of the research team. Adult participants had the option to review deidentified transcripts for accuracy. Participants were not involved in data analysis or interpretation.
Analysis
The overarching analytical framework followed reflexive thematic analysis practices by Braun and Clarke.Citation18 Reflexive thematic analysis involves building a deep familiarity with the data, and drawing upon the researcher’s assumptions, experiences, and positionality to understand how these aspects may shape the data.Citation16 This rich perspective, coupled with the theoretical flexibility of the framework, allows researchers to move beyond data summaries toward meaning filled stories that can guide clear outcomes and policy.Citation19 In this way, reflexive thematic analysis provided the ideal analytical tool for our study goal. NVivo (QSR International) was used as the analytic software. Coding was done independently through inductive methods, focusing on the semantic meaning by GB and IB. Initial codes were then compared to a previously made deductive code set developed by research team members (JAB, HM) from previous vaccine-related qualitative studies.Citation20–24 Using a constant-comparative and concept-development approach these codes were coalesced into cohesive themes, which were further refined in iterative discussion by the study team. Theme development was informed by voices of all stakeholders in order to capture commonalities as well as potential differences in perspectives.
Ethics approval
The study received the approval from the UBC Children’s and Women’s Hospital Research Ethics Board H18-00231. Each participating school board approved the study.
Results
Thirty-one (31) individual semi-structured interviews were conducted with parents, public health nurses, principals, and teachers and seven (7) focus groups were conducted with forty-nine (49) grade 6 students from four (out of 60) public school boards between November 2019 and May 2020 with participant characteristics described in . Most parents interviewed (15 of 16) indicated that their child was receiving the HPV vaccine this year.
Table 1. Participants’ characteristics.
Three overarching themes were constructed to identify opportunities for HPV vaccine education in SBIPs for grade 6 students in BC: 1) making SBIPs student-centered; 2) adopting a collaborative and interdisciplinary approach to vaccine education; and 3) actualizing parent education opportunities.
Theme 1: making SBIP curriculums student-centered
Students have varying vaccine knowledge and information sources
To help us understand what should be included in a vaccine curriculum and the topics that would engage students, we examined students’ understanding of vaccines. Most students appeared to have more knowledge around vaccines in general than specifically for the HPV vaccine. For example, students demonstrated a basic understanding of the different vaccine preventable diseases and the purpose of vaccines. With respect to HPV, some students knew that HPV could cause cancer and genital warts, while other students said they did not know what HPV caused or remained silent when the question was posed. Some students explicitly mentioned the link between HPV and sexual transmission, while others became uncomfortable or started laughing – hinting their discomfort with discussing of HPV as a sexually transmitted infection (STI).
The main sources of vaccine information for students were their parents, followed by peers, siblings, and teachers. Students indicated that parents and school staff rarely discuss vaccine information. If vaccines were mentioned this was usually while discussing vaccine day logistics or vaccine-related anxiety: “the only time we talk about shots [at home] is when either my brother or I are going to have to get a shot at school,” [student focus group 2]. Students stated the conversations about vaccines with peers centered almost exclusively on vaccine-related anxiety. Both parents and children stated conversations about STIs were “uncomfortable,” often resulting in the avoidance of such dialogue: “You could never get my wife to talk about this with my daughter, like, properly. There’s always euphemisms used for different body parts,” [parent from school B]. Online sources of vaccine information were cited infrequently by students. Some students were aware of the contentiousness of the topic of vaccines on the internet and acknowledged that the internet can be a source of both information and misinformation: “ … on the internet. It used to be a load of anti-vaccinators complaining about vaccines, but now it’s more people debunking most of their arguments,” [student focus group 4].
Building a student-centered curriculum
Many students expressed an interest in learning about both general vaccine knowledge and HPV disease, transmission, and vaccination in grade 6. Some students also emphasized learning about vaccines could help them make informed decisions about future vaccination choices: “I think all people should learn about vaccines because when you’re older, you make your own decisions … ” [student focus group 6]. Students mentioned how learning about vaccines could lessen vaccine-related distress: “Because if it’s something bad … than I’d be sort of excited to get it, so that it doesn’t happen to me, and then that would make me less scared,” [student focus group 2]. Moreover, students expressed an interest in learning about the general benefits of vaccines, such as learning about the diseases that vaccines help to prevent and the consequences of not getting vaccinated. Most students thought the HPV vaccine consent form and information sheet distributed in school were intended “for parents” and did not read it. Some students expressed an interest in a child friendly HPV vaccine information sheet.
The introduction of age-appropriate and fun learning resources for students was identified as a useful opportunity to improve vaccine knowledge. Most teachers, principals, and students reported being unaware of Kids Boost Immunity (https://www.kidsboostimmunity.com), a free online curriculum resource on a variety of vaccine and public health topics (e.g., HPV vaccine and global child health equity) for students in grades 4–12 supported by the BC Ministry of Health. However, upon learning about it, teachers and principals indicated they wanted to incorporate it in the classroom.
‘Fear of the needle’ as students’ central concern
While many students were supportive of vaccine education, some students expressed reservations due to the connection between vaccine education and vaccine day anxiety/needle-related discomfort. Some parents and students described the vaccine day experience as a period of transient distress. However, most students described the vaccination experience with strong negative valence descriptors, such as the pain of the needle and the emotional distress it causes. Most of the questions nurses and teachers received from students were about vaccine pain and associated anxieties. Notably, the anxiety appeared to be linked to needle discomfort and not the vaccine contents itself, as highlighted by one parent: “It’s the needle. Like, he’s not afraid of the vaccine itself. It’s the delivery mechanism” [parent from school C]. Some students also indicated their vaccine anxiety could impact not only their vaccination experience but also their parents’ decision to vaccinate them, as noted by one student: “I was complaining all night about how much it hurt, so my mum was sort of like, ‘Should you have not gotten the shot?’” [student focus group 2].
Several factors were found to either increase or decrease vaccine-related distress on vaccine day. Some students felt as if they were being lied to when there was a discrepancy between what school staff and nurses said and the reality of the day, as noted by one student: “It won’t hurt…it’s not true…liars,” [student focus group 1]. Similarly, students mentioned how diminishing comments such as, “It’s all in your head,” could be invalidating. According to parents and teachers, vaccine distress can be exacerbated by peers, often creating a domino effect: “One person gets a bit worked up and that sort of works other people up,” [parent from school D].
Students and teachers noted that empathizing with a student by “talking them through” their emotions and providing relaxation techniques could help. Students and nurses also knew that numbing gels could help with vaccine pain, while having a stress ball, bringing a stuffed animal or other distractions could help lessen needle-related pain. Given the prevalence of needle-related fear, many students, teachers, and principals suggested providing tools and education (e.g., in a vaccine curriculum) to address this anxiety before vaccination day.
Theme 2: adopting a collaborative and interdisciplinary approach to vaccine education
Teachers and nurses can have a positive effect on vaccine knowledge
Teachers, principals, and parents generally supported the idea of having a vaccine curriculum and believed both teachers and nurses could improve student vaccine literacy. As highlighted by one parent: “… I think that the school, they do fire safety for the kids … so why wouldn’t they do [vaccine education] for public safety? I think it should be included in the curriculum,” [parent from school E].
Parents described viewing teachers as a trustworthy authority figure who have the potential to positively impact vaccine knowledge. Parents, teachers, and principals also noted teacher-led education can play a crucial role in bridging knowledge gaps in HPV vaccine knowledge, particularly since many children reported feeling uneasy discussing HPV transmission with their parents. Parents firmly indicated that teachers should only provide fact-based information supported by public health recommendations and not express personal opinions or beliefs. Contrary to what some nurses or teachers indicated, parents broadly endorsed having teachers discuss how HPV is sexually transmitted with students, at least to provide a general understanding. In fact, some parents indicated that parents may not provide HPV vaccine information to their children, instead expecting the school to fill the role of vaccine educator: “I think right now, it seems the kids are a little bit in the dark especially if the parent doesn’t go through it [HPV transmission] with them, like what I neglected to do. I thought that the school might have discussed with them already,” [parent from school F].
Teachers, nurses, parents and principals also indicated public health nurses can have a positive influence on students’ vaccine knowledge, acceptance, and rates of vaccine uptake. According to principals, teachers and parents, nurse-led educational sessions prior to vaccine day would be beneficial for students, providing a “trusted source” of information and an opportunity for students to become more familiar with the nurses prior to vaccine day. As noted by one parent: “… I think [that nurses educating students] makes sense because the students would be familiar with them … [nurses would] come in to talk about it before the vaccination day. I think that the students might feel more comfortable because they’ve met [the nurses] once before, “. [parent from school B]
Minimal vaccine-specific education from nurses and teachers
Vaccine education is not currently part of the grade 6 science curriculum. Most teachers indicated they did not currently provide any vaccine education and their role was often circumscribed to managing vaccine day logistics: “We just give out the form and then the forms come back” [teacher from school G]. Teachers were interested in providing vaccine education, but identified numerous logistical barriers that could hinder its delivery.
Teachers faced many competing interests, and their role in vaccine education varied considerably depending on interest, capacity, and principal directives. The most frequently cited barrier to vaccine education was the lack of training and education, with teachers reporting that they were unable to answer student and parent questions. Most teachers indicated that they would like to have more training and education about the HPV vaccine. Additionally, some teachers noted how rigid provincial curricular guidelines limited their ability to provide vaccine education: “ … Only what you can say and this is only what you can teach, and we’re not supposed to go outside of that” [teacher from school F].
Historically, participants noted school nurses filled students’ vaccine knowledge gaps by providing direct teaching to students. However, funding cuts to public health have resulted in limited public health contact with schools outside of the vaccination day. As noted by one teacher, “And we have had a huge cutback on public health nurses coming in and educating … But kids need to see the frontline people … that has unfortunately been taken away in the last few years,” [teacher from school G]. Principals, teachers, and nurses broadly endorsed more support from administrative bodies: “I would really like to see something jointly put together by the Ministry of Education possibly and the health authorities in terms of having a curriculum around this because I do feel that education really is the answer to many of society’s challenges,” [principal from school G].
Theme 3: actualizing parent education opportunities
Many students and parents highlighted the significant role parents have in choosing to vaccinate their child for HPV, with most students and parents describing them as the sole decision-maker. As one parent stated, “Whether they [my children] like [the vaccine] or not, they’re getting it,” [parent from school E]. We examined parents’ current vaccine acceptance, HPV vaccine knowledge, their various knowledge sources, and opportunities for parent-directed education.
Although most parents consented to HPV vaccination (15 of 16), some still expressed reservations about HPV vaccination. The safety of HPV vaccines was the main concern. Parents’ knowledge about the HPV vaccine was variable. Most parents were aware that HPV is a STI linked to cancer and affects all sexes. However, some parents and teachers wrongly perceived HPV-related diseases exclusively affected females – mentioning it as a “girls” issue.’ As noted by one parent: “I thought it was for cervical cancer. Do boys – like, boys get HPV? That I had no idea either,” [parent from school E]. When boys were mentioned, it was often in reference to them being a vector for HPV and related diseases.
As with students, parents’ main HPV vaccine knowledge sources were relational networks, namely partners, family, and friends. Parents also referred to personal experiences when deciding to vaccinate their child, as highlighted by one parent: “There’s a couple of them [my friends] that weren’t going to [have] the HPV … vaccination because they didn’t believe their boys could get it. It was a girls’ virus. [I am] walking, living proof that no, boys can get it too. And their kids got vaccinated because I got sick,” [parent from school E].
When specifically asked by the interviewer, parents recalled receiving vaccine consent forms and information handouts from the school, but they did not refer to these sources when deciding whether to vaccinate their child. Some parents described the information on the consent form as “too clinical” or too long. Parents placed greater emphasis on online resources, such as news organizations or the BC Centre for Disease Control or the World Health Organization than students did. Moreover, parents described a high level of trust in the medical profession and often cited healthcare providers as a knowledge source, particularly if they had a well-established relationship.
We’re told that this is a good idea for vaccines, so we just kind of put some blind faith in the medical professionals and our kids get vaccinated for whatever’s available for the flu or for this HPV or for tetanus or whatever it is. [parent from school E]
The main opportunity highlighted by parents to improve their vaccine knowledge was to introduce nurse-led informational sessions for parents. Secondary to this was modifying existing HPV vaccine consent forms to be more straightforward and reader friendly. Parents underscored that hearing from health care providers would provide credible information grounded in real world examples:
… I’m a member of the [Parental Advisory Committee], and we would be quite open to talk about scheduling a health professional to come in and have sessions for parents … to hear about any clinics, vaccination, or any health concerns …. [parent from school B]
Discussion
In this study, we analyzed the perspectives of BC adolescents school staff, parents, and public health nurses on HPV vaccine education and SBIPs. Adding HPV vaccine education to the school curriculum received strong support among participants in our study, with three key opportunities emerging: making HPV vaccine curriculum student-centered, adopting a collaborative and interdisciplinary approach to vaccine education, and actualizing parent education opportunities.
Beyond their role in vaccine delivery, our findings highlight that SBIPs presented a unique opportunity to educate adolescents about vaccines and potentially improve HPV vaccine knowledge. In our study, students reported variable, albeit limited, HPV vaccine knowledge. However, many students expressed an interest in learning more about vaccines and suggested multiple strategies to improve vaccine education. Various studies have found health education is one of the few interventions that may decrease adolescent vaccine hesitancy and improve vaccine uptake.Citation7,Citation9,Citation10,Citation25 Given the myriad of competing demands and time constraints faced by teachers, complimentary non-resource intensive modes of education can be further integrated into curricular, like the online educational tool, Kidsboost Immunity (https://kidsboostimmunity.com).
Our study confirmed that students valued a SBIP curriculum that integrated their perspectives, met their needs, and engaged them. In the qualitative literature, adolescent perspectives on vaccines have often been missing, overlooking a critical stakeholder group.Citation13,Citation17 Several studies conducted among adolescents have found adolescents are interested in learning more about the HPV vaccine and being involved in the decision-making process.Citation26–30 In our study, participating students identified several different topics of interest about vaccines, such as managing vaccine-related anxiety, and the benefits of vaccination – all of which could be leveraged to design an effective vaccine educational intervention in SBIPs.
SBIPs also present the opportunity to improve parental vaccine knowledge and awareness. Students in our study reported that their parents were their primary vaccine knowledge source. Thus, understanding the perspectives and attitudes of parents is crucial for improving adolescent HPV vaccine coverage.Citation31,Citation32 Furthermore, enhancing parental knowledge may ultimately improve student knowledge about vaccines and help students and parents feel more confident in their decision-making abilities.
While vaccine knowledge is important, there are many other factors that affect vaccine acceptance. Our study demonstrated a disconnect between being vaccinated through SBIPs (high vaccination rates among study participants) and student/consenting parent/teacher knowledge (relatively low among study participants) possibly owing to a passive acceptance of the vaccine. This suggests that the current SBIP is sufficient for parents who are already supportive of the vaccine and do not require more vaccine information to sway their decision. However, current SBIPs may not meet the needs of parents and students with anxiety, questions, or hesitations. Integrating vaccine education into SBIPs is one potential strategy to increase vaccine acceptance among parents and students who are vaccine hesitant.
The source of the vaccine information is also important. Participants thought nurses and teachers should be involved in vaccine education for students and parents, with the caveat that the education be grounded in public health recommendations. School nurses are often regarded as advocates for child health and can be utilized as a trusted source of information to improve the success of SBIPs.Citation33,Citation34 Most BC schools no longer have school nurses, so alternate models need to be considered. Teachers could help fill the educational gap identified in our study and provide HPV vaccine information for students and parents.Citation34 A study in 2021, found that BC teachers support incorporating vaccine education in the school curriculum.Citation35 However, as our study participants highlighted, to effectively provide vaccine education, teachers must be provided the proper training and supports (e.g., time, funding, educational resources).
Limitations
Study interviews and focus groups were completed at the start of the COVID-19 pandemic. The pandemic may have led to different views on vaccines or public health recommendations, although we did not note differences in the themes expressed prior to or at the start of the pandemic. Experiences with the COVID-19 vaccine and the surrounding debates around adolescents’ right to self-consent to the vaccine may have changed teachers,’ parental, and students’ views around other vaccines, such as HPV – a topic that warrants exploration in future studies.Citation36
The data are subject to recall bias and social desirability bias since the participant data are self-reported. Among public health nurses, we were only successful in recruiting nurses from one health authority, who were both designated nurses at their respective schools. As such, their views may differ from public health nurses who are not designated to schools. We also acknowledge that parents participating in the study were generally supportive of SBIPs and HPV vaccination, with most parents deciding to vaccinate their child against HPV. Therefore, parents’ opinions in this study may differ from the broader population of parents, who may be less supportive of vaccination and more vaccine hesitant.
We acknowledge that individual interviews and focus group discussions are two distinctly different methods and that responses obtained through participant interactions in focus groups may differ from those obtained by adults participating in in-depth interviews. While fully exploring focus group interactions and how these influenced students’ responses is beyond the scope of this manuscript, we believe that including students’ voices adds an important perspective on the topic.
Future directions and policy recommendations
Successful SBIPs require buy-in from a variety of stakeholders, including teachers, principals, health staff, and parents.Citation34 By extension, having a collaborative and interdisciplinary vaccine education program, involving teachers, nurses, and other administrative bodies, such as the Ministry of Education and Ministry of Health, is crucial. Further exploration on integrating vaccine education in schools or universities may also hold promise to catch the attention of young adults before they have children. In our study, some participants reported funding cuts in public health nurse-led education limited potential opportunities for vaccine education. To address these shortcomings, there must be a prioritization of HPV vaccine education in schools prior to vaccine day. This involves equipping teachers with the training to provide HPV vaccine education, building a standardized vaccine curriculum, and providing nurses with the resources to teach about HPV vaccines and the opportunity to cultivate ongoing relationships with both students and parents. While public health and educational agencies may be able to instigate systems level changes to integrate vaccine education, the relational component that teachers and nurses provide remains foundational to education.
An effective SBIP should also address the main factors driving vaccine-related anxiety. For students in our study, one central concern was vaccine-related pain and associated anxiety, which is a form of vaccine hesitancy. Not only is needle-related anxiety distressing for children, but it may also affect parental and later adult vaccine decisions. There is increasing evidence that vaccine decisions are not unidirectional, and that adolescents can influence parent vaccine choices.Citation37 Even if parents make most vaccine decisions, vaccine pain and related distress may translate to future vaccine avoidance for the next generation of adults and parents.Citation37–39 It is thus crucial from both a humanitarian and public health perspective to reduce vaccine-related anxiety. Tools to reduce vaccine related distress highlighted in our study, which are also supported by the literature, include pre-vaccine education, KidsBoost Immunity, and the CARD system (comfort, ask, relax, distract) for pain and anxiety.Citation7–37–Citation40–42 Repeating this study for other childhood vaccines could also offer valuable insights on tailoring vaccine education for other recommended vaccines. Additionally, interviewing participants from schools with lower vaccine coverage or higher levels of parental vaccine hesitancy could provide a deeper understanding of parental perspectives regarding vaccine refusal and allow for tailored educational interventions.
In conclusion, current SBIPs used to deliver HPV vaccine in grade 6 would be strengthened by incorporating collaborative nurse-led and teacher-led vaccine education to deliver vaccine information that is relevant to students and parents, thereby informing current and future vaccine decision making and promoting fact-based health information.
Author contribution
JAB, HM and ED were involved with the conception and design of the study; JAB and HM were involved with data collection; JAB, HM, IB and GB were involved with the analysis and interpretation of the data; IB, GB, JAB and HM were involved with the drafting of the paper and all authors were involved with revising it critically for intellectual content and the final version to be published. All authors agree to be accountable for all aspects of the work.
Acknowledgments
The authors wish to thank all participants in this study who provided their time and insights into their decision-making processes and the support of the local school boards.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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