School Nurses' Attitudes Towards and Experiences of the Swedish School-Based HPV Vaccination Programme - A Repeated Cross Sectional Study

"The school nurse is a key person for information sharing about HPV..."

There is agreement that healthcare providers have an important role in the success of vaccination programmes, with some studies emphasising the importance of healthcare providers' communication skills in addressing parents' vaccine hesitancy. Included in the national vaccination programme for children in Sweden in 2012, the quadrivalent human papillomavirus (HPV) vaccine is primarily offered free of charge to girls aged 10-12 and is provided by school nurses. However, 1 in 5 girls is not vaccinated against HPV in Sweden. In that context, the aim of this study was to investigate school nurses' attitudes towards, and experiences with, vaccination against HPV and to compare the results with a similar study 3 years earlier. The 2013 study had found that, while most nurses were in favour of the vaccination programme, the majority had been contacted directly by parents who had concerns about the vaccine.

School nurses (n = 736) from all 21 counties in Sweden completed a 26-item questionnaire in spring 2016, 4 years after the implementation of the national HPV vaccination programme and 3 years after the previous survey.

Overall, the school nurses had more favourable attitudes towards the HPV vaccination programme compared to the 2013 study (p = 0.015). (According to the researchers, one reason for this finding is probably the reduced workload; since 2015, 2 doses are distributed with a time interval of 6 months instead of 3 doses given within 6 months.) More school nurses strongly agreed (86% in 2016 vs. 64% in 2013) that it was appropriate for HPV vaccination to be introduced into the general childhood vaccination programme. Over half of the school nurses strongly agreed (56% in 2016 vs. 41% in 2013) that boys should also be offered the HPV vaccine (p<0.001). A smaller proportion of school nurses believed that HPV vaccination might result in decreased condom use: 41% agreed strongly or partially vs. 51% in 2013. There were also fewer nurses (21% in 2016 vs. 23% in 2013) who believed that HPV vaccination might result in increased number of sexual partners. In addition, more nurses (67% in 2016 vs. 46% in 2013) agreed strongly that they had confidence in decisions made by authorities regarding HPV vaccination.

In the open-ended questions, fewer nurses (n = 366, 50%) reported difficulties with the vaccination compared to in 2013 (n = 570, 67%). In the content analysis of the open-ended questions, 4 categories emerged: 1) fear of needles and pain (n = 135, 37%); 2) logistical problems included workload, missing parental consent, and language difficulties (n = 65, 18%); 3) fear of vaccine side-effects and questioning from parents, including negative media reports (n = 53, 15%); and 4) girls' young age (n = 13, 4%). (For example, the researchers point to rumours and media reports of side effects, such as postural orthostatic tachycardia syndrome (POTS) and postural orthostatic tachycardia syndrome (CRPS), which can affect national vaccination programmes. Misconceptions can easily spread on the internet and social media and contribute to parents' concerns over the vaccine. However, the European Medical Agency confirms that the evidence does not support a causal link between the HPV vaccines and development of CRPS or POTS.)

Comparing the 2013 and 2016 surveys, and surprising to the researchers, there were no differences in school nurses' perceived knowledge about HPV in order to inform and to answer questions about the vaccine from the girls or from the parents. In the additional questions in the 2016 survey regarding knowledge of HPV vaccine, only about one-third (38%) agreed strongly that they had good knowledge about the safety profile of HPV vaccine. Almost all nurses (n = 659, 90%) had been contacted by parents with questions about the vaccine, and most questions were related to vaccine safety. More than half of the nurses (n = 409, 56%) reported they needed more education about HPV.

This study has demonstrated that, although the Swedish vaccination programme against HPV in many ways is well functioning, there is room for improvement. The researchers have previously found that school nurses who perceive higher levels of knowledge about HPV vaccine have more favourable attitudes towards the vaccination programme compared to school nurses with lower perceived knowledge. Most likely, school nurses who perceive sufficient knowledge about HPV feel more at ease in addressing parents' questions and concerns. One way to strengthen nurses' self-efficacy in order to address parents' vaccine hesitancy is by providing education and training about HPV and HPV vaccine. In order to meet the need for adequate knowledge about HPV vaccine, the public health agency in Sweden has updated the educational material dispersed to school nurses.

"Besides knowledge of HPV, studies also highlight the importance of healthcare professionals' communication skills....In communications with parents, school nurses should emphasise that HPV vaccine is safe and highly efficient in protecting against HPV-related diseases, especially when distributed to children before exposure to HPV. Addressing parents' questions and concerns might put at ease parental vaccine hesitancy, which might lead to increased vaccine coverage." One suggestion: Educational interventions might be delivered by the school nurse at parental meetings when time comes for parents' decision about HPV vaccination for their child.