School nurses’ perceptions of providing the HPV vaccine to adolescents in undervaccinated communities in Stockholm: A qualitative study

In Sweden, HPV vaccination is freely available to all adolescents aged 10-12 through a national, school-based program, but vaccine confidence and uptake are lower than for other childhood vaccines, with notable disparities between groups. School nurses are uniquely positioned to influence this, and the aim of this qualitative study was thus to understand their perceptions about the challenges associated with providing the HPV vaccine to adolescents in undervaccinated communities in Stockholm, Sweden. Between June and November 2024, we conducted 21 in-depth interviews with school nurses working in undervaccinated communities in Stockholm. The data was analyzed using inductive reflexive thematic analysis, which generated three themes: (1) School nurses are left to manage HPV vaccination by themselves; (2) Individual care and public health - the school nurses' dual responsibilities; and (3) Navigating sensitivity around HPV and sex. The themes illustrate how school nurses recognize their ability to influence uptake, but that various challenges, ranging from high workload to normative ideas about sex, hinder them. Our results suggest that ensuring high HPV vaccine uptake largely depends on the efforts of individual school nurses, which ultimately challenges the sustainability of the HPV vaccination program, indicating the need for further support for school nurses with regards to communication materials and strategies to addressing HPV vaccine hesitancy.