The Journal of School Nursing2025, Vol. 41(5) 557–569© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231214981journals.sagepub.com/home/jsn
Abstract
School nurses improve public health through vaccine promotion and mandate compliance. Despite recommendations and support for comprehensive adolescent HPV vaccination from organizations like the National Association of School Nurses as of 2023 only Virginia, Washington DC, Rhode Island, and Hawaii mandate HPV vaccine in schools. Virginia’s mandate allows caregivers to opt out of vaccination. It is important to consider how school-level vaccine compliance is associated with school and community factors. A multilevel analysis explored the association between school and county-level factors and HPV vaccination rates. This study shows schools that report higher rates of economically disadvantaged students had higher HPV vaccine coverage. HPV vaccine rates increased from 2019 to 2021 after the implementation of a gender-inclusive mandate. Virginia HPV rates still lag behind states with no mandate. The results suggest that school nursing practice related to HPV vaccine compliance may be impacted by community factors like economic status.
Keywords
communicable diseases, immunizations, community, Middle/Junior/High school, legal/ethical issues, quantitative research, human papillomavirus, vaccine
School nurses improve public health through vaccine promotion and mandate compliance activities for enrolled children (Bozigar et al., 2020). Because schools are microcosms of their surrounding communities, the health of individual students and that of the neighboring populace are often intertwined. Therefore, it is important to consider how school-level vaccine compliance is associated with both school and community factors (Sanford et al., 2021; Wheeler et al., 2021). In the United States (US), childhood vaccine mandates typically reflect the current recommendations from the Advisory Committee on Immunization Practices (ACIP) (ACIP, 2022; Centers for Disease Control and Prevention [CDC], 2023). However, the human papillomavirus (HPV) vaccine is a glaring exception to that generalization, even though the vaccine has been proven to be a safe, effective way to prevent six types of cancer (Adjei Boakye et al., 2023; Gee et al., 2016). Despite the ACIP recommendation and support for comprehensive adolescent HPV vaccination from prominent organizations like the National Association of School Nurses (NASN) and the American Cancer Society, as of 2023 only Virginia, Washington DC, Rhode Island, and Hawaii require adolescents to receive the vaccine for school enrollment (Yoo et al., 2020). Virginia was the first US locality to adopt an HPV mandate for school enrollment, which is an impressive accomplishment for a geographically and politically diverse state (Cuff et al., 2016). Virginia’s HPV mandate has evolved over the last 15 years since the initial mandate in 2008. In the beginning, only students designated female sex at birth were required to have three (3) doses of the HPV vaccine, with the first dose to be administered before the child entered the sixth grade. The bill that mandated the vaccine for school entry, House Bill 2035, also included the following opt-out clause, “After having reviewed materials describing the link between the human papillomavirus and cervical cancer approved for such use by the Board, a parent or guardian may elect, on an appropriate form prescribed by the Board, for his child not to receive the human papillomavirus vaccine.” (NCOSL, 2007) In 2021, the immunization mandate was amended to reflect the ACIP recommendations for vaccination regardless of biological sex. The current mandate as of October 2023, requires two doses of properly spaced HPV vaccine to be administered with the first dose to be given before the child enters the seventh grade. The parental choice to opt-out of HPV vaccination after reviewing health information remained a clause of the bill, but the requirement to document the parental refusal on an appropriate form was removed (NCOSL, 2020).
Considering the success of childhood vaccine mandates, Virginia should be a leader in HPV vaccination, but the state ranks 19th, far below other states with no mandate (Richwine et al., 2019; United Health Foundation, 2023). Consequently, Virginia offers a unique opportunity to explore HPV vaccine uptake at the school-level in the context of a gender inclusive, opt-out mandate. The recent publication by Wilson et al. (2023) highlights the important role school nurses have in the implementation of vaccine mandates. To best address low vaccination at the schoollevel, the sociodemographic context of the surrounding community should be explored. The knowledge gained from school-level analysis helps school health officials distinguish between practical barriers such as vaccine cost and motivational barriers like perceived disease risk.
Previous research efforts at national and state-levels show HPV vaccination uptake disparities. The 2021 National Immunization Survey (NIS-Teen 2021) showed that adolescents living in metropolitan statistical areas (MSA) had 9.0% higher coverage with ≥1 HPV compared to adolescents living in non-MSAs. Similarly, the adolescents living in non-MSA were 8.8% lower for up-to-date HPV vaccine coverage compared to MSA areas (Pingali et al., 2022). Furthermore, the difference between adolescent HPV vaccine rates in MSA and non-MSA areas was found to be statistically significant only when the family’s income was at or above the poverty level. Pingali et al. (2022) also found national vaccine rates for Tetanus, Diphtheria, and Pertussis (Tdap) (89.6%) and Meningococcal (MenACWY) (89.0%) to be higher than HPV (61.7%), which suggests that families may be selectively opting out of the HPV vaccine. The most recent NIS-Tenn Survey (2022) survey found similar vaccine coverage rates among adolescents when compared to the 2021 survey. However, vaccination among adolescents insured by Medicaid fell, which is concerning. Children insured by Medicaid are eligible to receive free federally funded vaccines, which theoretically should remove cost as a barrier. The 2022 NIS-Teen Survey also estimated Virginia’s HPV vaccination rate as 77.5% among adolescents aged 13–17 years, which is an approximately midway between the lowest rate of 61.0% in Mississippi and the highest rate of 94.6% in Rhode Island (Pingali et al., 2023). In addition to between-state HPV vaccine variations, studies also show differences in vaccination by jurisdiction within Virginia.
A study of statewide HPV vaccine rates in Virginia found that geographical disparities were significant with areas in the southwestern and northwestern parts of the state having the lowest vaccination rates. In addition, the areas of Winchester, Norfolk, Virginia Beach, Stafford, Sussex, and Petersburg were found to have significantly lower HPV vaccine rates than areas near Washington, DC, the Eastern Shore, and parts of central Virginia (Wheeler et al., 2021). The study used individual records obtained from the Virginia Immunization Information System (VIIS). Population density, percent Hispanic, and the average number of vehicles were significantly associated with higher completion of the HPV vaccine series among adolescents. At the time of the study, only providers that administered publicly funded vaccines were required to use the VIIS tracking system. Therefore, one of the noted limitations of the study was the potential for bias because individuals who qualify for publicly funded vaccines may be overrepresented in the study. Fortunately, future analyses will be more complete, because as of January 1st, 2022, new legislation requires all healthcare providers who administer vaccines in Virginia to participate in VIIS (Virginia’s Legislative Information System, 2021).
The underlying reasons for HPV vaccine disparities remain unclear, but several theories suggest cost may be a factor for families not eligible for free vaccines. Personal beliefs and motivation may also influence vaccine decision making. HPV is transmitted through close intimate contact unlike measles which can spread when a child coughs or sneezes in a classroom (Pingali et al., 2022). This difference in pathology leads to debate for mandated HPV vaccination. The hepatitis B virus is like HPV in that hepatitis B does not spread readily in school settings, yet the hepatitis B vaccine is mandated in most states and uptake is higher when compared to the HPV vaccine (Chen & Dang, 2017). Thus, it is clear that HPV vaccine decision making is complex and likely to change over time, which makes ongoing assessment vitally important (Strategic Advisory Group of Experts on Immunization, 2022). Understanding vaccination uptake at the school-level is salient to assessing the impact of the HPV vaccine mandate (Carhart et al., 2018). Virginia schools report HPV vaccination data to the Department of Health, which provides the opportunity to explore local data.
Even with a long-standing HPV vaccine mandate, Virginia’s HPV vaccination rate of 77.5%, while close has not yet reached the Healthy People 2030 goal of 80% for 13–15-year-olds. In addition, vaccine rates vary significantly within the state (Pierre-Victor et al., 2017; Pingali et al., 2023; Staples et al., 2021). To reduce HPV related cancers, it is critical to explore school-level vaccine rates (Kahn et al., 2023; Polonijo, 2020; Portnoy et al., 2020). Furthermore, Public Health 3.0 and the NASN Framework for twenty-first Century Nursing Practice acknowledges the critical role schools play in promoting community wellness through prevention activities like vaccination (DeSalvo et al., 2017; NASN, 2020).
This analysis of school-level data adds a deeper understanding of HPV vaccination rates in the context of a state mandate with an opt-out clause. HPV vaccine data has previously been studied using NIS-Teen data collection methods and by using vaccine data reported to VIIS. However, to our knowledge, a study of data reported at the school level in Virginia has not been done (Pingali et al., 2021; Wheeler et al., 2021). Thus, the objectives of this paper are to compare school-level data to the national and state-level findings, measure the difference in school-reported HPV vaccine rates by sociodemographic variables at the school and county levels, and compare HPV vaccine rates pre and post the genderneutral mandate in Virginia by comparing the 2019 data to the 2021 data. It is hypothesized that schools located in metropolitan areas, and those serving economically disadvantaged communities will have higher coverage of HPV vaccine for both males and females. It is also believed that there will be higher HPV vaccination rates reported in 2021. The Institutional Review Board at George declared this study [2057726-1] exempt from review.
This is an ecological cross-sectional quantitative study of public schools across the state of Virginia using publicly reported vaccine data. The choice was made to do a cross-sectional analysis, because there have been several recent changes to adolescent vaccine mandates in Virginia that complicate a year-to-year comparison. For example, in 2019 the requirement for Tdap vaccination was moved from 6th grade to 7th grade. Similarly, in 2021 the meningitis vaccine was mandated for 7th and 12th graders. These changes coincided with changes to the HPV mandate. Furthermore, school-level reporting was inconsistent for the 2019, 2020, and 2021. Due to the changes in state-level vaccine mandates, coupled with reporting variances, a multivariate cross-sectional analysis was selected for school year 2021. Summary statistics were calculated for HPV and Tdap vaccines in 2019 to compare rates pre and post the gender inclusive vaccine mandate. It is hypothesized that community and schoollevel factors influence school-level HPV vaccine rates, and therefore school nursing vaccine compliance activities.
The primary data set for this study was retrieved from the Annual School Self-Reports of Immunization Coverage: Student Immunization Status Report (SISR) publicized by the Virginia Department of Health. The data set is publicly available and can be found online. For the purpose of this study, and due to specifications in the current HPV vaccine mandate, data were restricted to data reported for students entering the 7th grade. Schools that did not include 7th grade students were removed from the data set. High schools, secondary schools, and elementary schools that included 7th grade were included. Private schools and schools that served special populations were removed from this analysis, because school quality variables were inconsistent or not available. Therefore, this study includes only public schools in Virgnia that serve 7th grade students and reported data for the 2019 and 2021 school years. SISR also contains vaccine-related variables including Tdap vaccination rates, the total number of children enrolled in the school, and the number of medical exemptions and religious exemptions. Tdap rates were considered in this analysis as a marker of vaccine access.
Additional variables were added to enhance the analysis and deepen the understanding of the sociodemographics of the school and the neighboring community. The results from the 2020 Presidential election were retrieved from the Virginia Department of Elections at the county level. The election results serve as a measure of the political leanings of voters within the county where the school resides. Conservative political ideology has previously been associated with lower support of vaccine mandates and states classified as Republican were found to have lower uptake of HPV vaccines among adolescents (Krok-Schoen et al., 2018; Suryadevara et al., 2019). The ratio of population-to-primary care physicians was retrieved from the County Health Ranking and Roadmaps and was included as a measure of access to preventative services at the county level. A focused review found areas in the US with a higher density of primary care providers had better health outcomes including improved access to preventative vaccines (Shi, 2012). School-level sociodemographic data was retrieved for each of the schools included in the study from the Virginia Department of Education’s School Quality Profile Report. Sociodemographics, like those captured in the School Quality Profile have been linked with health outcomes (Lim et al., 2019). For example, nurses serving schools with high rates of chronic absenteeism may experiences different vaccine compliance barriers compared to nurses in schools with high presenteeism. Finally, a variable for urbanicity was retrieved from the US Department of Agriculture. The zip code for each school was available, therefore, the choice was made to use the primary Rural-Urban Commuting Area Codes (RUCA) classified by zip code. The RUCA was used to create a variable to classify the school as residing in a metropolitan or non-metropolitan area (United States Department of Agriculture, 2010). Urbanicity was considered because rural areas reported lower rates of HPV vaccination when compared to urban areas (Pingali et al., 2021). The fall 2020 immunization data was excluded because of reporting inconsistencies during the COVID-19 pandemic. Due to the potential impacts of the COVID-19 pandemic on chronic absenteeism for 2021, the choice was made to use data for absenteeism from 2019 in the cross-sectional analysis of the 2021 immunization data. A list of the variables included in the study along with definitions and indications can be found in Table 1.
All statistical analyses were completed using STATA-BE 17 software. The unit of analysis for this study is the public school in Virginia that serves 7th grade students. The continuous dependent variables, HPV vaccination rate for males and females, was analyzed separately. Independent variables include the categorical variables political affiliation (Republican or Democrat), urbanicity (metropolitan area (code 1-3) or nonmetropolitan (code 4-10)-1), racial/ethnic subgroup (Asian, Black, Hispanic, White), period (2019 or 2021). The following numerical variables are included in the analysis: chronically absent students, Tdap vaccine, total enrollment, medical exemptions, and religious exemptions.
Individual summary statistics were calculated for numeric and categorical variables. Mean and standard deviation were calculated for the numeric variables. Frequency and corresponding proportions were calculated for categorical variables. Bivariate analyses were conducted for each independent variable and the outcome variable HPV vaccine rate by male and female. Tableau software was used to create maps of the mean HPV vaccine rate per county by sex for the schools that reported vaccine data in the fall of 2021.
A multilinear regression model would assume independence of the schools within each county and equal variance of the various counties in the dataset. However, it is evident that the schools are nested within counties and schools within the same county are likely to be similar. To ignore the multilevel structure of the data may bias regression estimates and standard errors. A review of the literature was conducted to find statistical methods that would account for the multilevel analysis of HPV vaccine data in Virginia. Several studies used multilevel analysis techniques(Abebe et al., 2012; Babalola, 2009; Estep, 2018; Paudel et al., 2022). Paudel et al. (2022) and Abebe et al. (2012) used fixed effects at the first level and random effects at the second level. Estep (2018) asserted that mixed-effects models approach can take advantage of both within-first level and between-first level variation (Abebe et al., 2012; McNeish & Kelley, 2019). A multilevel mixed-effects linear regression was used to analyze the HPV vaccine rates reported by the schools with variables at both school and county level. The analysis was performed using mixed (mixed y x || lev2:), estat ICC, and estat IC commands in Stata17 BE with a statistical significance set at p < 0.05.
To determine the best model fit the Intra-Class Correlation (ICC) and the Akaike Information Criterion (AIC) were calculated. In this study, the ICC is a measure of correlation in HPV vaccination rates among schools that are within the same county. ICC indicates the amount of variation in vaccination rates that is accounted for by variation between counties. An ICC value of 0 indicates that all variability in vaccination rates lies within the counties. Conversely, an ICC value of 1 indicates all variability in vaccination rates lies between counties and schools within a county have the same vaccine coverage. If an ICC is high (>0.10) a multi-level model should be considered. For the purpose of this analysis, it was determined that a multilevel model would be used if the ICC was greater than 0.10 (Jones & Subramanian, 2013). Models are created using different combinations of variables. The AIC is a measure of goodness of fit and can help reduce the complexity of statistical models. Selecting the model with the lowest AIC offers the best compromise between simplicity and accurately fitting the data (Portet, 2020).
All models were run separately for males and female rates. The first model run was a null model which included only the dependent variable (HPV vaccination rate) and the higher-level grouping unit of interest which in this case was the county (Model 1). Model 2 included all school-level variables. Bivariate analyses were conducted for all school-level variables, and the results were used to construct Model 3. Model 3 included only school-level variables that were found to be significant in bivariate analyses which included Tdap rate, the rate of economically disadvantaged students, medical exemption and total enrollment. Model 4 included the county-level variables. Model 5 included all the independent variables. The best fit model (model 3) was selected based on the AIC (Monsalves et al., 2020).
A total of 417 schools were included in the 2021 original data set. Each school included in the data set was found on the Virginia Department of Education’s School Quality Profiles database. If the school did not have 7th graders, the school was removed from the data set. After the schools were removed, there was a total of 339 public schools for 2021 and 396 schools in 2019. The schools were in 118 counties within the state of Virginia (Table 2). Most of the schools were in areas that were considered metropolitan. Fairfax County had the highest number of schools with 7th graders (n = 21) followed by Prince William County (n = 17). Both counties are located in Northern Virginia. Most counties reported data from 1 school (n = 64) that served 7th graders. Descriptive statistics for the categorical variables can be found in Table 3. Summary statistics are available for the numeric variables in Table 4. Vaccine rates for the HPV vaccine and the Tdap vaccine from 2019 to 2021 can be compared in Figure 1. The reported rate of HPV vaccination for male and female students increased by 27.3% from 2019 to 2021. The reported Tdap rate decreased by 5.6%. Most counties in Virginia voted for the Democratic Party in 2020 (54%) and most counties were classified as metropolitan (77.6%). The mean number of students enrolled in school was 238 students, but the range was wide with one school reporting as few as three students while the largest school reported 729 students. The mean rate of students classified as economically disadvantaged was 48.1%, and the mean rate of students classified as having a disability was 14.5%. There was a mean rate of 11.1% for chronically absent students in 2019. The mean vaccine rate of reporting schools was calculated per county by sex and can be seen in Figures 2 and 3.
The ICC for the null models (model 1) were .313 (males) and .362 for (females) indicating that between-county variance cannot be ignored and therefore a multilevel model is preferred, because of a high level of clustering of school reported vaccine rates within counties. Model 2 contained all the first level variables. First level (school) variables found to be significantly associated in bivariate analysis were included in model 3 (Tdap vaccination rate, medical exemption, economic disadvantaged and total enrollment). Model 4 contains second level (county) variables. Model 5 contains all the independent variables. According to the AIC, model 3 was the best fit for both males and females. Tdap vaccination rates and the rate of students classified as economically disadvantaged were significant for males and females in model 2. The findings were consistent for both the male and female models. The results for the models can be found in Table 5 for males and Table 6 for females.
The coefficient for the rate of children considered economically disadvantaged (0.20) found in Table 5, indicates that as the rate of students classified as economically disadvantaged increases so does the rate of HPV vaccination for male students. Given that the p-value associated with this coefficient is 0.001, it suggests that the economic status has a statistically significant effect on the HPV vaccination for males within model 3. This finding is similar to the findings in model 3 for female students, The coefficient for the female model found in Table 6 is 0.18 with a corresponding p-value of 0.002. Tdap vaccination rate was also significantly associated with male and female vaccination rates. In model 3, for every one percentage point increase in the Tdap vaccine coverage rate, the HPV vaccination rate is estimated to increase by approximately 0.56 points for females and 0.51 points for males. The p-value of < 0.001 was found for both sexes. No other variables were found to be significantly associated with the HPV vaccine rates.
Overall HPV vaccine rates in Virginia are on the rise, but there are still schools reporting very low vaccination rates. The mean vaccination for HPV vaccine increased for both males and females from 2019 to 2021, but it remains unclear if the increase is due to reporting differences, a response to the gender inclusive mandate, a reaction to the COVD-19 pandemic, or a combination of factors. It is very likely that Virginia schools are implementing the opt out mandate differently, and it is also possible that schools are underreporting HPV vaccine rates, because children are not excluded from school if that vaccine is missing. Similarly, the current legislation no longer requires written declination from parents that opt out of the mandate (NCOSL, 2020). The liberal opt out clause has previously been cited as a reason for Virginia’s lagging vaccine uptake (Yoo et al., 2020). Consequently, most schools report much higher rates of Tdap when compared to HPV. This study shows that schools that report higher rates of economically disadvantaged students had higher HPV vaccine coverage. Thus, strengthening the theory that economic status is linked with HPV vaccine uptake (Pinagli et al., 2021). Tdap vaccine coverage rates were significantly associated with HPV vaccine coverage rates. The relationship between the two vaccines provides evidence that bundling adolescent vaccines may be an effective intervention for HPV vaccine series initiation (Rand et al., 2020). School-reported data appears to trend differently when compared to the VIIIS data (Wheeler et al., 2021). As seen in Figure 2 and 3 the areas of southwestern Virginia reported higher vaccine rates for both sexes when compared to the northeastern area of the state. More research is needed to understand if the differences are related to vaccine uptake or reporting differences. Understanding the community and school-level factors associated with HPV rates is important particularly for school nurses in states like Virginia with HPV vaccine mandates. Unlike findings from previous studies on the individual level, this study did not find a significant association for HPV vaccination rate and the ethnic/racial majority group within the school. This could be due to a lack of precision of school-level data to detect small differences that occur at individual level.
Virginia’s school nurses are tasked with implementing a unique vaccine mandate. The school-level analysis shows significant variations in HPV vaccine rates. This school-level analysis adds evidence to the existing theory that economic affluence is associated with lower rates of HPV vaccination. A study of the COVID-19 vaccine found a similar association between economic status and vaccine uptake (Kozlov, 2021). If well-resourced families are choosing not to vaccinate children, school nursing interventions to promote vaccination will likely differ depending on the populations served in a school (Roberts et al., 2018). For example, school-based vaccine clinics in well-resourced areas may be poorly attended if motivation rather than access is the main driver of low vaccine rates. In areas with low motivation, resources may be better invested in interventions that improve knowledge of vaccine safety and efficacy or that provide communication tools to school nurses (Cole et al., 2022).
Identifying the gaps in immunization at the school-level can help school nurses pinpoint groups of students who are unvaccinated allowing outreach and interventions to be tailored in areas and populations with lower HPV vaccination coverage (Fisher et al., 2022). When other adolescent vaccine rates are significantly higher than HPV rates, it can indicate to school nurses that students and parents may benefit from targeted education that focuses on the safety and efficacy of the HPV vaccine (Mattebo et al., 2021; Wilson et al., 2023). Likewise, monitoring how schools are implementing the opt out HPV vaccine mandate across the state can indicate which schools may benefit from educational resources. Theoretically, opt outs should be rare, and therefore schools with the lowest HPV vaccine rates may benefit from vaccine targeted interventions that consider the context of the local communities. Knowing a school’s vaccination rate and how sociodemographic factors are associated with vaccine uptake supports data driven decision making by school health officials.
Using school-level data, school health administrators may provide practical resources, like vaccination clinic events, to aid school nurses that serve schools with practical vaccine barriers. Conversely, administrators may support professional development to enhance skills in vaccine communication, promotion and record keeping for school nurses that serve populations with low vaccine motivation (Strategic Advisory Group of Experts on Immunization, 2022). Using school-level data also reinforces the role school nurses play in general public health efforts. The work school nurses put into vaccine compliance activities goes beyond the student’s time at school. Recognition of the lifetime individual and public health benefits a vaccine can bestow may normalize the inclusion of the HPV vaccine with other childhood vaccines. The public health benefits of comprehensive school-based HPV vaccination are already being noted in the reduction of HPV-related cancer around the world (Ebell, 2021; Hall et al., 2019).
The association between Tdap and HPV rates coupled with the increase in HPV vaccination from 2019 to 2021 may be a sign that HPV vaccination is becoming normalized with other adolescent vaccines, however the quantitative data only tells part of the story (Zhu et al., 2022). It remains important to understand how the vaccine mandate is being implemented from school to school and district to district across Virginia’s schools. That knowledge lies with school nurses. School nurses may also possess an understanding of local barriers that prevent children from receiving the HPV vaccine that are difficult to measure quantitatively. Therefore, future research should qualitatively explore the individual experiences of school nurses in promoting and administering the HPV vaccine across the state of Virginia. Addressing HPV vaccine disparities can reduce related cancers, which is particularly important in the southeastern US where health inequity has led to higher cervical cancer burdens for certain groups (Francoeur et al., 2022).
The American Cancer Society suggest initiating HPV vaccination at age 9 and bundling the second dose with other adolescent vaccines to improve series completion rates (Brandt et al., 2023). Provider promotion of the HPV vaccine at age 9 may lead to more frequent discussion of HPV between parents and nurses that serve elementary schools. In Virginia, high school seniors are required to get a second dose of the meningitis vaccine which presents another opportunity for school nurses to recommend HPV series initiation or completion (Kajtezovic et al., 2023). Thus, all school nurses play a role in HPV vaccine promotion.
There are limitations to this analysis. First, this is a crosssectional analysis of vaccination data and does not show how the rates trend over time. Second, not all schools reported vaccine data, and reporting schools likely have variations in how vaccine data was collected and reported. The COVID-19 pandemic may have caused disruptions in access to preventative services such as vaccination appointments. The gender inclusive mandate became effective in July 2021 and data from the fall of 2021 may not show the mandate’s true effect yet. Thus, consistent data collection, reporting and longitudinal analysis will deepen our understanding of the school-level mandate overtime. Finally, this analysis excluded private schools and public schools with special populations which limits the findings from this analysis.
HPV vaccines rates continue to lag behind other adolescent vaccine, and disparities in uptake are evident when schoollevel data is considered. Schools that reported higher rates of economically disadvantaged students had higher rates of HPV vaccination among males and females. Similarly, Tdap vaccination rates were positively associated with HPV vaccination rates. HPV vaccination rates were higher in 2021 after the implementation of the gender inclusive mandate when compared to 2019 when a female only mandate was in place. The mean vaccination rate for schoollevel data was lower regardless of gender than the mean for Virginia reported in NIS-Teen 2022. A continued focus on school-level data and the role of school nurses in adolescent vaccine compliance is particularly important to assess the success of the mandate for Virginians and for other states considering a full or opt out mandate. Similarly, a focus on local, school-level data is consistent with Public Health 3.0 and the NASN framework (DeSalvo et al., 2017; NASN, 2020). With more complete school-level reporting, the accuracy of data analysis can be improved. Similarly, the collection and interpretation of school-level data can only be fully appreciated if nurses involved in compliance efforts are included in the research process. Future research should include qualitative data collection to explore the experiences of school nurses with vaccine compliance.
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
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Kimberly McNally is a PhD candidate at George Mason University and a public health nurse in the School Health Division of Fairfax County Health Department.
Ali Weinstein is an expert in well-being and has extensive experience with qualitative methods to include thematically analyzed semi-structured interviews with health professionals.
Lisa Lindley is an expert in health promotion, health behavior theories, and has extensive practical experience in HIV/STI prevention among adolescents, LGTBQ+, and underserved populations.
Robin Wallin is an advocate for school nurses with experience developing, implementing, and evaluating school-based health programs. Dr. Wallin serves as a liaison between various departments within and outside the school system and has experience writing health policies for the school system.
Amira Roess is an expert in multidisciplinary approaches to infectious disease epidemiology and has extensive experience with statistical analysis, vaccine hesitancy, and health disparities.
1 Department of Global and Community Health, George Mason University College of Public Health, Fairfax, VA, USA
2 Alexandria City Public Schools, Alexandria, VA, USA
Corresponding Author: Kimberly McNally, Department of Global and Community Health, George Mason University College of Public Health, Fairfax, Virginia, USA. Email: kmcnall2@gmu.edu
