Discussion
To the best of our knowledge, this is the first study to examine the attitudes and experiences of school nurses regarding a HPV vaccination programme at the population level.
School nurses have a key role in the success of the implementation of vaccination programmes. Therefore it is crucial that they have adequate knowledge about HPV and skills to ensure that they feel comfortable with all the procedures related to the vaccinations. Adequate knowledge and appropriate ongoing education about HPV among healthcare professionals (HCPs) are necessary in order to promote vaccine coverage. Thus, the nurses who had a positive attitude to the HPV vaccinations and were confident with their training were likely to be more at ease when providing information to parents and children, managing their concerns and obtaining informed consent. School nurses have a unique position in informing parents and addressing their questions and concerns (and clarifying any misunderstandings) regarding HPV vaccination. Their communication skills regarding HPV vaccination are essential to foster parental acceptance and to promote public health. Recommendations from HCPs are associated with better HPV vaccine uptake. Thus, HCP education and knowledge about HPV as well as communication skills are important since the majority were contacted by parents who had additional questions about the vaccine, especially its adverse effects. The necessity for HCPs to discuss vaccine safety and effectiveness with parents was also noted in previous studies. The safety profile of the HPV vaccine is well established, and no severe adverse effects have been found. Thus, if this information is highlighted more clearly in the printed information provided to parents, some of their concerns may be alleviated. This would also make the task of obtaining informed consent easier for school nurses.
The school nurses perceived that they had an increased workload in implementing the HPV vaccinations and this was also reported in studies from the United Kingdom. The available financial support had not been used to a great extent to cover the extra expenses for the vaccinations, and therefore it was not surprising that nurses reported difficulties in implementing the programme because of time constraints. Thus, it is important to identify strategies to provide direct financial support to cover the additional expenditure incurred by the vaccinations, thereby ensuring the continued success of the HPV vaccination programme.
The professional role of school nurses includes preserving and promoting health equality. This might have been reflected in the finding that the majority agreed that boys should also be vaccinated. Other childhood vaccinations are offered to both boys and girls, so the exclusion of boys may be viewed as an ethical dilemma, which was also noted by Malmqvist et al.. Another consideration was the attitude to the age of girls when they received the vaccination, where one-third of nurses believed that girls should be slightly older because it would have been easier to provide them with appropriate information about HPV. A majority of the school nurses also believed that parents who did not consent should be offered the option of having their daughter vaccinated at a later time. This was consistent with our previous findings about parents not consenting to vaccination. Nevertheless, there is an ethical dilemma of the public health benefit of mass immunisation versus individual autonomy. Even if it would be beneficial for an individual family to be offered vaccination at a later time, this could affect the vaccination programme and eventually lead to lower vaccination coverage. In addition, a delay in vaccination might lead to a decreased health benefit for the individual. Therefore, it must be emphasised to school nurses that the reason for vaccinating at such a young age is to give the best possible protection against HPV. One way to overcome this is by handling HPV vaccinations like all other childhood vaccinations, such as measles-mumps-rubella (MMR) vaccination. Parents who decline the MMR vaccine are contacted by the school nurse, and are offered a second chance to vaccinate. This contact with the school nurse could also be an opportunity for parents to ask additional questions about HPV and the HPV vaccine. However, it is important to emphasise that the vaccine is prophylactic, and parents should be informed that it needs to be received before possible exposure to HPV, i.e., before sexual activity commences.
Strengths and Limitations
A major advantage of this study was the high response rate. School nurses from all 20 counties in Sweden participated, and also from both private and public schools, so the results may be generalised to the whole population of school nurses involved in the HPV vaccination programme in Sweden. One caveat is that we could not be sure that school nurses from all of the 290 municipalities in Sweden participated in the survey. The use of a web-based survey allowed many nurses to participate and to respond within a short period. A possible limitation is that we could not prove that only school nurses answered the questionnaires. The national official web page was directed exclusively to school nurses, but personal identification was not required before completing the questionnaire. To overcome this limitation, we checked all the demographic data to ensure that no school nurses had responded more than once. Another possible limitation is the lack of information about non-responders.
It would have been interesting to investigate whether the attitudes of the school nurses correlated with the coverage rate, but this was not feasible as the data were not available at the time of preparation of the manuscript. Since January 2013, it has been mandatory to report vaccinations within the national childhood vaccination programme to the National Vaccination Registry in Sweden.