Abstract
In all US localities, students provide proof of compliance with vaccination requirements to attend school. Despite benefits, vaccine legislation remains contentious. The human papillomavirus (HPV) vaccine is recommended for adolescents and prevents cancer, but its inclusion in school immunization requirements is challenged. Virginia was the first state to mandate HPV vaccination. HPV is the only required vaccine in VA that allows caregivers to elect out. School nurses are trusted members of communities and enforce vaccine compliance. This study aims to understand Virginia school nurses’ practice in implementing the HPV vaccine mandate through the exploration of their subjective experiences. Semi-structured interviews were conducted. Thematic analysis using the socioecological model guided data analysis. Factors that influence nursing practice were identified at all socioecological model levels The data from this study is intended to provide an understanding of school nursing practice so that interventions to improve HPV vaccination rates can be developed.
Keywords
communicable diseases, immunizations, community, middle/junior/high school, policies/procedures, school nurse knowledge/perceptions/self-efficacy, qualitative research
In all United States (US) localities, students must provide proof of compliance with vaccination requirements to attend school. School entry vaccine mandates date back to 1850s and have helped eliminate the spread of communicable diseases like smallpox (Malone & Hinman, 2003). Currently, the Advisory Committee on Immunization Practices (ACIP) recommends certain immunizations. State law determines which vaccines are needed for school enrollment, and if exemptions can be made (Attwell et al., 2018). Vaccination benefits the recipient with immunity and also reduces the number of susceptible people capable of transmitting disease (Conis, 2015; Dubé et al., 2015; Wilson et al., 2023). Nonetheless, vaccine mandates are sometimes seen as coercive and unethical. For example, the human papillomavirus (HPV) vaccine is recommended for adolescents, but is not required for school enrollment in most states (Abiola et al., 2013; Charo, 2007; Richwine et al., 2019; Roberts et al., 2018).
The HPV vaccine prevents certain types of cancer and is transmitted through non-casual skin-to-skin contact (CDC, 2021; Franco et al., 2019). Cancers associated with infection typically occur in adulthood, and therefore the threat of an acute outbreak in the school or community is innocuous. Nonetheless, Hepatitis B (Hep B), a virus analogous to HPV in some respects, is required in many states (Chen & Dang, 2017). Currently, only four US localities, Hawaii, Rhode Island, Washington DC, and Virginia (VA), require the HPV vaccine, while 46 states require Hep B vaccine (Immunization Action Coalition, 2021). School requirements led to widespread uptake of the Hep B vaccine and a significant decrease in infections and related cancers (Chen & Dang, 2017; Pattyn et al., 2021). Similarly, in areas where there is high HPV vaccine rates, significant decreases in related cancers are being reported (Hall et al., 2019). Therefore, it is important to consider HPV vaccine mandates as a critical tool for cancer prevention.
Although the HPV vaccine is safe and effective at cancer prevention, few states have successfully passed school mandates (Abiola et al., 2013). VA was the first state to mandate the vaccine in 2008 (NCOSL, 2007). The VA mandate has been amended several times since 2008, but the most current version states, “The Board’s regulations shall at a minimum require…Two doses of properly spaced HPV vaccine. The first dose shall be administered before the child enters the seventh grade. … Because HPV is not communicable in a school setting, a parent or guardian, at the parent’sorguardian’s sole discretion, may elect for the parent’s or guardian’s child not to receive the HPV vaccine, after having reviewed materials describing the link between HPV and cervical cancer approved for such use by the Board” (VLIS, 2021). Religious and medical exemptions may be used for all required vaccines, but the HPV vaccine allows parent/guardians to elect out of the vaccine for any reason after reviewing educational material. The state removes the penalty (exclusion from school) for those that elect out of the HPV vaccine (Savulescu et al., 2021). Previous research by Pitts and Adams-Tufts (2013) suggests that although VA’s mandate allows caregivers to elect out of vaccination, the statute led to increased skepticism and distrust among parents. Carhart et al. (2018) conducted interviews with HPV vaccine stakeholders in VA and found barriers to vaccination at each socioecological model (SEM) level which included: knowledge gaps, sexual concerns, time constraint, inconsistent recommendation, lack of leadership, lack of informational support, and an ineffective mandate. Another recent study that considered sociodemographic and geospatial variations in HPV vaccination rates in VA found contrasting associations between sociodemographic factors and vaccine initiation and completion (Staples et al., 2021). Thus, more knowledge is needed to understand the implementation of HPV vaccine requirements.
School nurses are trusted members of local communities and are involved with vaccine compliance (Bozigar et al., 2020; Combe, 2021; Wilson et al., 2023). Yet, there are no studies that focus solely on VA school nurses’ experience related to the HPV vaccine mandate. The aim of this study is to examine VA school nurses’ experiences implementing the HPV vaccine mandate through the exploration of their subjective experiences. The SEM was chosen as a framework for this study (Carhart et al., 2018). The data from this study is intended to provide an understanding the school nursing experience in order to better inform evidencebased interventions aimed at improving HPV vaccination rates.
A descriptive qualitative study was initiated using purposive sampling techniques to identify school nurses that had experience with adolescent immunization in VA. Initially, recruitment was restricted to public school nurses; however, a nurse from a Catholic school expressed a desire to participate. Their experiences are included in the study. Nurses who did not have HPV immunization experience and those who did not speak English were excluded. Nurses who were not registered or licensed practical nurses were excluded. The Institutional Review Board (IRB) at George Mason University declared this study [2057726-1] exempt from review.
On July 2023, school nurses were recruited during the Summer Institute of School Nursing (SISN) sponsored by the Virginia Department of Health. The SISN allowed nurses to be recruited from across the state of VA. Nurses were also recruited by posting study recruitment flyers on the Virginia Association of School Nurses (VASN) and the National Association of School Nurses’ (NASN) public discussion boards. In addition, the Director of School Health Services for Fairfax County and Alexandria City Public Schools sent recruitment emails with study details to school nurses. Finally, study flyers were mailed to middle schools throughout VA. The main author shared details of the study to include confidentiality, protection of participant identity, risks, benefits, and the voluntary nature of the interview with all participants. A 25-dollar gift card was offered as compensation for a 30–45-min interview.
Individual semi-structured, virtual interviews were conducted from July 2023 to September 2023. A predetermined interview guide helped ensure the collection of similar types of information from each participant. Prompts helped produce socially relevant knowledge on factors influencing school nurses’ vaccine practice. The interview guide was reviewed by the authors to ensure the questions were nonleading, clearly worded, and participant oriented (Qu & Dumay, 2011). The study’s purpose was explained to each participant, and verbal consent was given before each interview began. Participants also granted permission for the interviews to be audio recorded. The recordings were transcribed by one of the authors. Apart from removing any identifying information and minor grammatical corrections, transcripts were verbatim. The de-identified transcripts were imported into the qualitative data analysis software MaxQDA. Transcripts were password-protected, and participant identity was anonymized with a unique 3-digit identifier (Watkins & Gioia, 2015). In addition to the interview questions, participants were asked to complete a short demographic survey.
Thematic analysis methods were used by two nurses, one of whom conducted the interviews. Initially codes were created inductively by the main author and interviewer. Codes were reviewed by a second coder and discussed until consensus was achieved. Codes were then deductively organized using the SEM. Codes were interpreted within the SEM to identify distinctive and repetitive themes (Clarke & Braun, 2017; Hennink et al., 2017; Rujumba et al., 2021). Themes were developed at intrapersonal, interpersonal, organizational, community, and societal levels (McLeroy et al., 1988). The coders reached consensus on themes and researcher reflexivity and member checking were employed to improve trustworthiness of findings. The results present a summary of the themes and quotes are presented to illustrate the themes. Quotes are reported with the participant number in the text and Table 2.
The nurses represented 16 counties from across VA. All the participants identified as female (n = 20), and most were 30 to 49 years of age (n = 12). Half of the participants were registered nurses with a bachelor’s degree (n = 10). Most of the participants identified as White (n = 14). Almost all the nurses were parents (n = 19) and served only one school (n = 18). Half the nurses classified their school(s) as serving a rural community (n = 10). All nurses had experience and knowledge with adolescent vaccination. A summary of sociodemographic statistics can be found in Table 1.
Several themes were identified at all levels of the SEM and are shown in Figure 1. Themes are outlined in Table 2. In total, 13 themes were identified. Three themes were identified at the intrapersonal, interpersonal, and policy level. Two themes were identified at the organizational level and community level.
The intrapersonal level focused on individual-level factors. Knowledge was conceptualized as possessing accurate information about HPV, the vaccine, and vaccine legislation. Belief referred to the nurses’ reflection on the importance, safety, and efficacy of the HPV vaccine. Attitude was conceptualized as the nurses’ thoughts and feelings about the inclusion of the HPV vaccine with other required vaccines.
The school nurses that participated in this study were knowledgeable about the role of HPV infection in the development of certain types of cancer. The nurses also knew the vaccine is available to and recommended for adolescents. Participant 852 concisely stated, “I know the HPV vaccine helps prevent cancer and the spread of the virus that can create cancer.” Several nurses discussed the importance of gender inclusive vaccination, the value of vaccinating adolescents prior to exposure, and acknowledged progression from infection to cancer can take many years. Participant 179 captured the need to vaccinate children before infection. “We know that there is a vaccine to prevent HPV and prevent the future cancer in both males and females, but it is best administered early in the preteen years.”
Participant reported positive attitudes about vaccination in general. For example, when asked if some vaccines are more important than others participant 643 stated, “I’m all for vaccinations, prevention, and keeping people out of the hospital.” Professional and personal experiences influenced attitudes about HPV vaccination. A participant remembered patients undergoing treatment for cancers that could have been prevented with the HPV vaccine. Another participant considered how their own diagnosis with HPV influenced their support of vaccination (Table 2). Participant 150 shared also shared a commitment to cancer prevention, “I like it because I know if we can prevent cervical cancer, what a God send that is.” Despite positive attitudes, some felt targeting adolescents at age 11 was too young and made a distinction between the HPV vaccine and other required vaccines. Participant 626 expressed her attitude as positive but did not feel the HPV vaccine should be compulsory because the vaccine was perceived as too new. “To be honest, I think it’s a great vaccine. I really do. I’ve done some research on my own. But I do feel like it is still somewhat new. So I do feel like parents at this time should have the right to do their own research, communicate with their child’s pediatrician to get some direction.” Participant 872 believed receiving multiple vaccines at one time could be detrimental. “I mean, that’s a lot of vaccinations to go pumping in at one time. I get the hesitation.” Although most school nurses believed the benefits outweighed the risk of side effects, concerns arose around safety and efficaciously. Participant 129 stated, “I don’t really see that there is as much research as I’d like to on the vaccine to prove its longevity. That it’s going to prevent HPV related cancers, decrease the number of cases we’ll see in another 20,30, 40 years, and the side effects, you know, we don’t know enough about it.”
Interviewees were generally aware that the HPV vaccine is required for school children in VA but were unclear on how to interpret and implement the statute. For example, a nurse was uncertain if their district enforced the requirement. Confusion came from the district’s use of the word “optional” in their HPV vaccine promotion efforts. Similarly, participant 778, recalled “In one of the robocalls, I only included Tdap and meningitis, because I didn’t want to upset parents. They’re going to go to their healthcare provider. They’re going to talk about vaccines. We’d already sent the letter home with the HPV information in it. Then, of course, I had a representative very upset, because HPV wasn’t on the robocall. I explained to her why it went out that way.” The nurses struggled to understand the current vaccine legislation that both requires the vaccine but also allows caregivers to decline with no consequences. Participant 626 expressed ambiguous understanding of the statue in relation to the other required vaccines. “In the state, there are certain shots that are required, and here at the middle school, the biggies are Tdap and meningococcal. HPV is highly recommended. At this time the state is allowing parents to decline.” The participants’ responses suggest that school nurses grappled with the meaning of the statute, and used contradictory words like mandatory, required, optional, opt-out, and recommended.
The focus of the interpersonal level was the relationship between the school nurse and parents/guardians. In VA, adolescents cannot independently consent for immunizations. Therefore, the parent/guardian makes the decision to vaccinate. Interview questions were designed to elicit information on how school nurses communicate with parents and how nurses perceive the interactions.
School nurses used multiple methods to communicate with parents. One of the most frequent ways nurses provided HPV vaccine education was through an annual letter created by the VA Department of Health (Figure 2). Organizational factors (time constraints) and societal (stigma) factors impeded follow-up on missing HPV vaccine data. Participant 797 reflected on their current practice. “If the student has Tdap and meningitis we did not reach out to parents to ask about HPV. I just typically look up in VIIS to see if they had received it or not, but I don’t reach out and say this is required.” Participant 778 received unexpected negative feedback from written communication. “Last year we put HPV Vaccine in our letter. These are the required vaccines and had all 3 listed. I got a million calls from parents, not a million, but I probably got a dozen calls or more from parents saying, but HPV is not mandated. My child’s not going to get HPV vaccine.” Typically, in cases where HPV vaccine documentation was not submitted, school nurses inferred that the parent or guardian had opted out, and no additional measures were pursued.
Although communicating with families could be difficult, a nurse from an urban school district reflected on the importance of verbal communication. Participant 380 felt that talking openly could normalize the vaccine. “HPV should be openly discussed and there should be more explanation about it. Other people still have not heard about it unless somebody talks to them personally about it. So, for example, in my own like circle of friends, I’m always checking, are your kids already immunized with HPV? And they said, are the boys included? That’s when it becomes an ordinary part of an ordinary topic. Then it becomes normalized just like any other vaccine, just like Hep B or other vaccines. It becomes part of the routine vaccines that we should be receiving.” When asked to reflect on parental engagement, participant 469 stated, “I have not had parents asking me about HPV, but if they do, I highly recommend it.”
Participants did feel their recommendation influenced the vaccine decision-making process. In some cases, nurses felt families had made up their minds prior to their recommendation, and that those that chose to delay or refuse the vaccination, were unlikely to change their minds. Conversely, Participant 998 recalled a positive encounter. “Most of the time I’ve talked to parents they’re not opposed to it. There are some who say I really need to think about this more. So, I think probably the two biggest responses I had was that they would either just go ahead and get the vaccine, or that they would say, I just need to think about it. I don’t recall really anybody being adamantly against getting it.” Participant 953 saw value in their recommendations even if caregivers did not acquiesce to vaccination at the time. “I think it opens the door for conversation with the doctor. I don’t know if it pushes them one way or another, but I think it gives them the information to say, okay, I do need to ask my doctor about this shot.”
Participants reflected heavily on language when communicating the HPV vaccine requirement. Language was important because nurses did not want parents/guardians to feel information regarding the HPV vaccine requirement was knowingly withheld. Omitting mention of the opt-out clause felt deceptive. Participant 872 discussed enforcing the vaccine requirement while maintaining trusting relationships with the families. “I don’t push and press. I must be transparent, because if you’re going to come to me and be like well, you didn’t tell me this. I will say I told you everything. I put it in that paper. I would encourage you to get it, but there is an option for you to opt out is what I say.” Participants were reluctant to challenge caregivers’ decisions, but they were motivated to educate parents. Enforcement of the vaccine requirement was seen as secondary to providing accurate information for parents to make an educated choice for their child. Correspondingly, participant 797 felt that caregivers lack adequate information. “I think there’s still a lot of misconceptions from parents, and I think that might be what hold some of them up from agreeing to get that vaccine with the others that they’re getting.”
The organizational level focuses on the school where the nurse practices. Although the HPV requirement is a state policy, school nursing practice is influenced by formal guidelines, such as written procedures, and informal guidelines, such as the environment and culture of their school.
Participants reported competing demands played a significant role in their nursing practice, and time constraints were a significant barrier. When nurses were asked what could be done at the school-level to improve vaccine compliance, many wanted help gathering vaccine records, inputting the vaccine data, and following up with delinquent families. Participant 797 reported vaccine compliance as ongoing. Efforts begin long before the start of the new school year and continues as children are catching up on the required vaccines. “I do a phone call in March or April for our upcoming school year then in August specifically for our rising seventh graders and our rising seniors.” The participants suggested that integrating school health records with VA Immunization Information System (VIIS) would reduce the time spent locating and inputting vaccine records. Additionally, participants noted that designation of additional staff to support vaccine enforcement efforts would allow nurses to spend more time on follow-up and education.
Participants reported support from leadership and school staff. Participant 643 felt empowered by their school administrators. I feel like I’m very fortunate to have an administrator who supports me. Not only at the district level, but in my building. Concerns did arise around unclear work roles. For example, some participants recalled being the sole individual responsible for gathering vaccine records. Without designated staff, vaccine compliance tasks were left undone when the nurse was absent. Contrastingly, Participant 380 stated when schools had specialized staff, assigned to vaccine compliance activities, nurses could focus on the additional healthcare needs of the student population. “There are some nurses who are assigned specifically for immunization compliance. They can do that well because they’re not distracted by other things.”
The community-level focused on the cultural norms and built environment around the school. Additionally, the participants were asked about community partners that supported their nursing practice related to vaccination compliance. Nurses were also asked to reflect on the availability and accessibility of vaccines for families in their community.
Private medical providers were frequently mentioned as community partners for vaccines. However, the nurses cited serval challenges for caregivers that wished to receive vaccines through private medical offices. For example, participant 626 reported that private medical offices often required the children to establish care before children could receive vaccines. “We were told that the student or the parents would have to establish care with their facility. We’ve heard a couple of parents say, well, I don’t want to establish care for my child. I just want to get the required immunizations. I think that is something we could certainly continue to work on. I believe we do need to bridge that gap.” When there were few pediatric providers in a community, families may wait a long time for a vaccine appointment. Despite the challenges, nurses felt confident that providers recommend the HPV vaccine to families that come in to receive the other required vaccines. When families were unable to access vaccines through private providers, participant 780 referred families to the local health department. “Some parents are not able to get into their pediatrician, but the health department is picking up and doing some vaccines.” Participant 129 concurred, “There is a limited number of pediatricians. Thankfully, the health department has a lot of clinics, and they do free vaccines.” Health departments were frequently identified community partners. Participant 179 noted health departments offer accessible and free or low-cost vaccine services to families. “We partner with our health department, and we have fantastic partnerships. We help arrange vaccine clinics. Our schools allow the health departments to come in after school, and on Saturdays to hold vaccine clinics.” Unfortunately, some families still struggled to get vaccines. Practical barriers to vaccination were attributed to lack of affordable transportation, work schedules, and inadequate staffing at the health department. Participant 852 recalled, “I have a family who’s living in a subsidized housing area but there’s nothing around them. They can’t walk to the grocery store. They can’t walk to a doctor, certainly not a doctor’s office. The parents don’t have any transportation.” Participant 029 stated, “I think it’s a matter of getting them to the health department. We don’t really realize it, but we have people who are really, really poor. They may not even have bus fare to get to the health department for their free vaccines.” Due to access barriers, nurses expressed the value of holding immunization events at the school. Participant 778, from a rural school district, described the different types of immunization opportunities available through collaborations in their community. “On the first day of school the health department has walk-in appointments available. In addition, all summer, having days that they could call to schedule their appointment with the local health department. After that we had a mobile vaccine provider set that up centrally located in our community. Some people might have had to drive 30, 40 min to get there, but it was in the center of town to give vaccines after Open House. The health department has not been as accepting of going into the schools. We did have one clinic at the local high school, and we did 58 students that night from 2:30 to 6 PM.”
None of the participants in this study reported storing or administering vaccines at their school and relied on community partners to access required vaccines. For that reason, school nurses wished to make the most out of their collaborations with community partners. Several nurses recalled large immunization events that were poorly attended and proposed school-based, family oriented, events to improve turnout and build community trust. Participant 626 suggested, “We could make it somewhat of a fun environment like a back-to-school kickoff. We could give out supplies, in a carnival scene and then also get you up to date on your shots.” Participant 629 stated, “Yeah, the back to school one is well attended because they also get free school supplies. It’s like, hey, come, get your free shoes, and since you’re here you might as well get the shots as well. That one tends to be well attended with a lot of participation.”
Nurses were asked to consider how the state-level policy influenced their nursing practice. Nurses also spontaneously reflected on societal stigma related to reproductive health services and how that stigma impacts HPV vaccine promotion and decision-making in the school setting.
Participants stated the HPV vaccine statute policy lacked enforcement power. Thus, making the bill a paper tiger, a paper tiger is defined by the Oxford dictionary as a thing that appears threatening but is ineffectual. The policy challenged participant 780. You know the HPV requirement; parents can opt out. You don’t have to prove anything. You don’t have to do anything, and so I think it’s just very confusing. Participant 469 was empowered to enforce the requirement for Tdap and meningitis vaccines through the threat of exclusion from school, but that was not true for the HPV vaccine. “We don’t have children excluded [for missing HPV vaccination]. The main thing them being compliant with the mandatory ones.” Similarly, participant 994 stated, some parents chose to receive only the vaccines that would prevent their children from attending school. “I have seventh graders, and they have the mandatory vaccines like Tdap and meningitis. I would like for them to have a HPV, but a parent can opt out of that if they choose to which a lot of parents do.” Considering the challenges, participants were asked if they felt the current statute should be modified. Participants expressed contradictory views. Some felt that the vaccine should be required like Tdap and meningitis. Participant 029 said, “We have a mandate, but I feel like let’s just have it a flat-out mandate. Instead, it puts our nurses in like this very awkward position of trying to explain to the parents about the opt out.” Participant 872 felt a full mandate would lead to an increase in community distrust and prioritized awareness over altering the existing mandate. “I’m personally okay with it but I can understand when you are mandated to do something that it pushes you to go against it. Educating people on why it’s important is the main priority. Put education above a mandate. Education is better than saying, you must get this done, or else! Putting stipulations like that, is what makes people like, what are you doing? You know, making conspiracy theories.”
The route of HPV exposure was prominent in discussions. No questions were asked to specifically prompt the participants to discuss the vaccine in terms of sexual health, but the connection clearly impacted the school nurses’ practice. Participant 158 viewed vaccination pragmatically but struggled to overcome the societal classification of HPV as a sexually transmitted infection/disease (STI/STD). “I see a lot of people who are resistant to it, and still consider HPV as strictly that sexually transmitted disease. I guess they think that their sweet darling isn’t going to be doing that. It’s mandated by the state of VA, but parents don’t want their kid getting it, because it’s the STD type thing.” Similarly, participant 179 reflected on promoting the HPV vaccine at age 9 and stated, “It’s kind of scary, because I don’t think parents will be very receptive if we administer it any earlier. Personally, I think that they’re not very receptive about it even being administered in seventh grade, because they just don’t believe that their kids are sexually active, but we have sixth and seventh graders getting pregnant.” Overcoming the stigma of the vaccine as an “STD” vaccine was noted particularly difficult in a conservative community. Participant 988 stated, “I don’t know how many of them take it, and how many still have preconceived notions given the religiousness of our community. I think a lot of them still very much tied this to an STD. I think it’s going to take something larger than the nurse. It is going to take public health campaigns to really educate. because it’s not just my religion. It is most religions who have a very strong sense of wait until marriage or wait until you are older. Whatever it is, the vaccine has been tied so strongly to STD that that there needs to be some really good public health education going out.”
The COVD-19 pandemic brought renewed attention to vaccines and mandates. The participants were asked if the COVID-19 pandemic impacted their nursing practice related to vaccines. Participant 273 felt that vaccine rhetoric in the media negatively impacted acceptance of all vaccines. “I know somebody very close to me, who now doesn’t want to vaccinate their child at all because of COVID-19. The COVID-19 vaccine had pushback from people.” Participant 780 attributed the decrease in vaccine motivation to mistrust for the scientific community and the proliferation of pseudoscientific news on mainstream and social media. The negative perception is how they made the COVID vaccine, but I don’t know why people think any of the other vaccines changed. I think there’s just mistrust with science, what is science, and social media drives all of that with fake news.” However, participant 469 felt that since the COVID-19 pandemic, their community had improved the ability to host immunization events. I think there are more clinics and more resources out there. We have gotten better with clinics over time, and with getting the resources to the community.”
This study sought to understand the experiences of school nurses related to the implementation of the HPV vaccine requirement in VA within the SEM framework. Our analysis identified 13 themes that deepen our understanding of their experiences. The nurses that were interviewed are knowledgeable about the HPV virus and the vaccine. Generally, the nurses feel the vaccine was safe and the vaccine should be administered to middle schoolers. The findings from this study are consistent with other studies (Rosen et al., 2016, 2017). Concern at the intrapersonal level is related to the belief that current research is not sufficient to show the vaccine is safe and effective. Similar concerns were noted in earlier studies that explored the attitudes and experiences of school nurses (Grandahl et al., 2014; Rosen et al., 2017). Our study findings suggest that concerns for safety and efficacy persist. Our novel research shows VA school nurses are aware of the HPV vaccine requirement but did not know how to implement the statue in their school. At the interpersonal level, written communication was the most frequently reported method for reaching families. The participants were hesitant to follow-up with families who had not submitted documentation of an HPV vaccine. The lack of follow-up is likely due to multiple factors, but previous research suggests that communication tools can empower school nurses to communicate with students and families about the HPV vaccine (Bozigar et al., 2020; Swift et al., 2022). Despite communication challenges, participants felt their professional recommendation was important. Ensuring that school nurses are well-equipped to discuss HPV and the vaccine with parents/caregivers is important because school nurses may have the opportunity to have multiple conversations with the families (Rose, 2017). School nurses want to maintain the trusting relationship with families and are explicit about sharing the caregiver’s right to elect out of the HPV vaccine requirement. The school nursing role requires that communication be consistent, the vaccine recommendation be strong, but prominence also be placed on the nurse-caregiver relationship (Runngren et al., 2022). At the organizational level, vaccine compliance activities require a lot of time. Participants discuss the ongoing efforts needed to advertise vaccine requirements, collect vaccine records, input the records, and follow-up with delinquent families. Nurses also manage the day-to-day responsibilities of the school health office. The competing demands reduce follow-up on delinquent HPV vaccine records. Teamwork is important to school nurses, because school nurses may be the only healthcare workers in a school (Grandahl et al., 2014; Hilton et al., 2011; Nodulman et al., 2015). Overall, the nurses felt very supported, but having additional staff assigned to vaccine compliance activities was invaluable. Support from school staff is essential for increasing vaccine follow-up. At the community level, participants relied on strong relationships with community partners, because they did not store or administer vaccines at school. Private medical providers and local health departments were the most cited community partners. Staffing shortages, appointment availability, and transportation barriers prevented some families from accessing available vaccines. Family-focused, convenient vaccination events were favored as a way to vaccinate while building trust. Previous research supports the value of strong community partnerships as a way to support school nursing practice to improve HPV vaccinations rates (Bozigar et al., 2020; Clavé Llavall et al., 2021; Cunningham et al., 2021; Nodulman et al., 2015). At the policy level, participants in this study felt that although the state technically requires HPV vaccine, but they are not empowered to enforce the requirement. Previous studies have cited the statute as a reason that HPV vaccine rates in VA (77.5%) fall short of other states with requirements like Rhode Island (94.6%) (Carhart et al., 2018; Cuff et al., 2016; Pingali et al., 2023; Wheeler et al., 2021). Thus, the statute is viewed as more of a recommendation than a requirement. Nurses were also divided on their attitude regarding the requirement. Some nurses support removing the parental choice option, while others strongly believe that caregivers should be allowed to decline the vaccine. Efforts to distance the HPV vaccine from the stigma of an STI need to continue (Daley et al., 2016; McKenzie et al., 2023). Participants spontaneously discussed the challenges associated with promoting the HPV vaccine in the school setting, and support largescale, media campaigns to address some of the misconceptions about the HPV vaccine. The COVID-19 pandemic response has caused increased vaccine hesitancy in many of the areas where the participants practice. Wilson et al. (2023) highlight the importance of evidence-based interventions to help school nurses improve local vaccine rates while managing societal factors like vaccine misinformation and medical mistrust.
The data from the interviews is not generalizable to all school nurses and only represents a small group of nurses in VA. However, the study shares the insight of individual nurses and their experiences implementing a unique HPV vaccine mandate. Despite efforts to limit researcher influence on participants, there is always a possibility that a voice inflection, misplaced probe, or unintended facial expression may influence a response. Researcher reflexivity and member checking was used to improve trustworthiness (Galletta, 2013). Other limitations include variations in participant engagement and difficulty recruiting participants particularly those from less resourced schools (DeJonckheere & Vaughn, 2019). Although efforts were made to recruit diverse perspectives, many school nurses were not able to or chose not to participate in the study. Despite the limitations, this study adds valuable insight for school nurses, school administrators, and other public health officials.
The existence of an HPV vaccine requirement presents an opportunity and a challenge for school nursing practice in VA. At the intrapersonal level, many nurses have positive attitudes about the HPV vaccine and vaccination in general and feel the vaccine can prevent cancer. Unease around safety and efficacy suggests intrapersonal interventions should focus on decreases in HPV-related cancers while highlighting the vaccine’s safety record (Fisher et al., 2020; Kennedy et al., 2014). Interpersonal data suggests relying on written communication misses opportunities to engage with parents about the HPV vaccine. Interpersonal interventions should focus on empowering nurses to communicate, educate, and connect with families about HPV infection and prevention (Cole et al., 2022; Wilson et al., 2023). Organizational interventions should support vaccine teams to address vaccine compliance (Burns et al., 2021; Selvan et al., 2021). Community-level interventions should build partnerships. Health departments provide an alternative for families that are unable to access vaccines at private provider offices. When health department resources are limited, partnerships with pharmacies, mobile vaccine providers, or neighboring counties can be supportive (Clavé Llavall et al., 2021; Nodulman et al., 2015; Runngren et al., 2022). Significant stigma and the current legislation’s failure to disincentivize undocumented HPV vaccines influence nursing practice (Savulescu et al., 2021). Societal impacts of the COVID-19 pandemic are still unclear, but research suggests the pandemic exacerbated distrust in vaccine mandates and public health (Wilson et al., 2023). Lawmakers and administrators should incorporate school nurses in the development of policies and procedures. School administrators, nursing managers, and school nurse coordinators should encourage school nurses to participate in professional organizations like NASN and VASN so that their voices are heard on issues like adequate staffing and vaccine compliance efforts. School nurses are trusted in the community, have ongoing relationships with families and students, and are critical to the reduction of HPV-related cancers.
School nurses in VA play a vital role in improving HPV vaccination rates. This study provides insight on how the HPV requirement is being implemented across Virgina. Through the nurses’ shared experiences, themes were identified at each level of the SEM. The themes highlight key areas that may influence nursing practice and lay out an opportunity to strengthen the enforcement of the HPV vaccine mandate in VA. Public health officials and school administrators should consider interventions to support nursing practice related to the HPV vaccine requirement at the different levels of the SEM.
Dr. Robin Wallin is currently affiliated with Arlington Public Schools.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article
Kimberly McNally https://orcid.org/0000-0003-4967-6805
Ali Weinstein https://orcid.org/0000-0002-3371-6086
Robin Wallin https://orcid.org/0000-0003-0427-5928
Supplemental material for this article is available online.
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Kim McNally is a registered nurse and PhD candidate at George Mason University’s College of Public Health. She is a school health nurse with the Fairfax County Health Department and is certified in infection control.
Dr. Roess is a professor of Global Health and Epidemiology at George Mason University’s College of Public Health. She is an epidemiologist with expertise in infectious diseases epidemiology, multi-disciplinary, and multi-species field research and evaluating interventions to reduce the transmission and impact of infectious diseases.
Dr. Weinstein is a Professor of Global and Community Health and a Senior Scholar in the Center for the Advancement of Well-Being. She has extensive experience conducting human biobehavioral experiments in the laboratory and field, conducts survey research, as well as a small research portfolio of qualitative research.
Dr. Lindley is an associate professor at Lehigh University College of Health. She specializes in health intervention that prevent HIV/STI and unintended pregnancy and advances LGBTQ + well-being through health promotion and education.
Dr. Wallin is a certified pediatric nurse practitioner and the director of school health services for Alexandria City Public Schools. She is passionate about school health, school-based healthcare services and supporting school nurses in their roles as front-line public health practitioners.
1 George Mason University College of Public Health, Fairfax, VA, USA
2 Lehigh University College of Health, Bethlehem, PA, USA
3 Alexandria City Public Schools, Alexandria, VA, USA
Corresponding Author: Kimberly McNally, MSN, RN, CIC, George Mason University College of Public Health, 4400 University Drive, Fairfax, Virginia, USA. Email: kmcnall2@gmu.edu
