HPV vaccine education in British Columbia

In this episode, Dr. Hana Mitchell joins us to talk about the barriers to HPV vaccine uptake, the role of schools in vaccine awareness, vaccine anxiety and parental involvement, integrating educational resources in schools, and much more.

Learn more about topics discussed in this episode:

Kids Boost Immunity

Opportunities for HPV vaccine education in school-based immunization programs in British Columbia, Canada: A qualitative study, Human Vaccines & Immunotherapeutics

Vaccine Evaluation Center at BC Children's Hospital

All episodes written and produced by the Research Communications team at BC Children's Hospital Research Institute.

Theme music: "Life Is Beautiful" by Anastasia Kir

Transcript

Kristen Hovet (00:00)
My name is Kristen Hovet and I'm a research communications specialist for BCCHR. Joining me today is Dr. Hana Mitchell, a pediatrician and researcher at BC Children's Hospital specializing in infectious diseases. Dr. Mitchell co-authored a research article titled, "Opportunities for HPV vaccine education in school-based immunization programs in British Columbia, Canada: A qualitative study," which was first published online in March 2024 in the journal Human Vaccines and Immunotherapeutics.

Hana Mitchell (00:35)
I'm Hana Mitchell and pronouns I use are she hers. I'm a pediatrician at BC Children's Hospital specializing in infectious diseases. And I do research at the Vaccine Evaluation Center. And of course, as an infectious disease pediatrician, I know that vaccines are one of the best ways of preventing infections. But in order for people to get vaccinated, they have to be aware of the vaccine, have access to it, and understand a bit about why the vaccine is recommended.

In Canada, we use school-based vaccination programs to hopefully vaccinate as many children as possible against vaccine-preventable diseases, including HPV. And traditionally, the school-based vaccination programs have focused on delivering the vaccines, but were not linked with vaccine education. We wanted to know whether our school-based vaccine programs in BC could be used not only to give the HPV vaccine, but also as an opportunity to inform children and their families that the vaccines, such as HPV, are important, and hopefully therefore encourage them to get vaccinated and contribute to vaccine knowledge and confidence going forward.

Kristen Hovet (01:42)
For listeners who might not be familiar, could you explain the importance of the HPV vaccine and also why it's typically offered to students in Grade 6 here in British Columbia?

Hana Mitchell (01:53)
Of course, yes, so HPV stands for human papillomavirus and that's a sexually transmitted virus that can cause a number of cancers in males and females. And these cancers usually happen in adulthood to people in their 30s and 40s. And we are so fortunate because the HPV vaccine is extremely effective in preventing infections and therefore preventing cancers. For example, in females who have never been infected with HPV, the vaccine prevents almost 100% of cervical cancer that the virus can cause. 

In BC, we use school-based vaccination programs in Grade 6 to give the vaccine. There are two reasons why we give the vaccine to children rather than adults. The first one is really simple: children just develop a better immune response. Their body remembers the vaccine better and they need fewer doses of the vaccine to achieve the same effect. And secondly, it is of course best to be vaccinated before you've ever been exposed to the virus. And what that means is that the vaccine is best given to children before they reach adolescence and before they start having sex.

Kristen Hovet (02:59)
And despite the availability of the HPV vaccine for youth in Canada, unfortunately, uptake is still below the 90% target. What are some of the key barriers that contribute to this lower coverage?

Hana Mitchell (03:12)
They're barriers to vaccine coverage on several levels. And maybe I'll start with the individual [level]. It is a somewhat newer vaccine. It's been offered in BC for girls since 2008 and for boys since 2017. So many people who are parents right now may have heard about the HPV virus, but would not have been vaccinated when they were going through school themselves. And for some people, the fact that this is a newer vaccine has led to some uncertainty and mistrust. They say we would like to see the vaccine around for a bit longer before we decide, before we are comfortable with our child being vaccinated. People also may not understand why a vaccine that prevents infections or cancers that happen to adults is recommended for children who are school age. And they think that it's perhaps better if their child gets the vaccine later when they can make their own decisions and once they become sexually active. So people might feel that getting the vaccine in Grade 6 is early. 

Earlier messaging around the vaccine focused on this being a vaccine for girls and young women. And even though we now recommend the vaccine for boys and girls, or for women and men, the messaging that this vaccine is somewhat different stuck with people a bit. And I wonder whether that also influenced the decision to get vaccinated to some degree. So these are some individual level factors. 

On a public health level, we can't forget the school-based vaccine programs got really disrupted by the COVID-19 pandemic. Even though the study that I'm talking about was done just before the pandemic, school closures really limited access to the vaccine. And in 2020, probably almost no one got vaccinated through the school and we're just now starting to catch up. So we have a lot of homework to do. 

Outside of the pandemic, school-based vaccination programs are a great way of reaching children, but they're not perfect. School-based vaccination programs require consents and some children have trouble returning consent forms. That can often happen if life at home is chaotic for whatever reason, if parents do not understand English and have difficulties finding translated forms or understanding what is required from them. And of course, last but not least, some children for whatever reason do not attend school. So not everyone is reached through the school-based programs.

Kristen Hovet (05:28)
Your recent work highlights the fact that HPV vaccine education isn't formally included in the BC Grade 6 curriculum. So what are the potential impacts of this educational gap on students' knowledge and confidence around vaccines?

Hana Mitchell (05:45)
School education is so important and we know that teenage years are the time when we start making a lot of our own decisions about what clothes to wear, how to spend our weekends, and increasingly about our health. And I think schools are one of the places where students can get reliable scientific information that helps them think critically and make well-informed decisions about many things in life, including vaccines. 

We know that not everyone talks about vaccines at home. Parents might not know what to talk about, like we found in our study. They might not feel comfortable talking about vaccines, especially if they are vaccines that prevent sexually transmitted infections. And they might hope that this will be done in school or at the health-care provider's office. And, you know, Grade 6 students who are otherwise healthy don't usually see doctors or nurses. So there's kind of limited opportunities for health-care providers to talk to them about vaccines and make recommendations, and they probably don't look up vaccine information online. If they do, depending on the student, they may or may not know where to look for reliable information. 

I think what happens in schools right now is that many students get the HPV vaccine through the school-based vaccine program, but they actually have no idea why they got the vaccine or what the vaccine is for. And likewise, if they didn't get the vaccine, they do not know what they did not get vaccinated against. So I really think that talking about vaccines in school in an objective factual way provides a really important opportunity to hear about the vaccines, receive reliable science-based information early on in someone's life, and gives children the language to talk about vaccines and ask questions and know where to look up information. 

And of course, vaccine knowledge and confidence depend on many factors that evolve over life. But I do think that vaccine education in school is just one of the best ways of providing children with a solid foundation and knowledge about vaccines that they can then build upon.

Kristen Hovet (07:41)
Vaccine-related anxiety and fear of needles were significant concerns for the students in your study, maybe surprisingly. What strategies could schools or health-care providers implement to help reduce these concerns and improve vaccination experience?

Hana Mitchell (07:58)
Absolutely, and students had a lot to say about vaccines. And one of the things that kept coming up over and over when we talked to Grade 6 students was that they're not afraid of the vaccine itself or the side effects. They're really afraid of the needle and of the pain of getting the shot. 

I think, again, going back to education, Grade 6 students understand a lot. And a lot of them said, well, if we knew why we were getting the vaccine and what the vaccine is helping prevent, it wouldn't take away the pain from the needle or that fear, but it would make it more acceptable. It would make it more bearable because we would understand why we're getting the vaccine and what it is preventing. 

Other things that students and teachers told us: students like seeing trusted, known people around to support them. Teachers often help with a lot of the logistics and just having a teacher who they trust nearby, telling them that it's okay to get vaccinated and maybe hold their hand or encourage them was really, really valued by students.

Honesty from the nurses and teachers was important. Students like hearing the truth. They don't want to be told that it's not going to hurt or that this is not stressful. So, just acknowledging that this is hard and that it's okay to be worried and that they'll get through that was important to students. 

Distractions help a lot. All children across the board thought that vaccine days should be more fun. You know, like having some games, children talked about therapy dogs in school, music in school, just making it fun, getting a little reward for what they've done. It obviously boils down to a bit of logistics and what's doable on a vaccine day, but just adding a bit more colour and fun to it so that it's overall a positive experience, even if the needle itself is something that students are worried about.

Kristen Hovet (09:41)
Also, parents play a crucial role in deciding whether their child gets the HPV vaccine. In fact, for many students, parents are the sole decision-makers on whether the student receives the vaccine. So how can schools and health-care professionals better support parents in this particular role?

Hana Mitchell (09:58)
Exactly. In Grade 6, students need parental consent to be vaccinated. And then in Grade 9, there is an opportunity for students to provide mature minor consent as a catch-up. But in Grade 6, it really boils down to whether the parent has consented or not. From a logistical perspective, schools should make consenting as easy as possible for parents. And in our study, we found that many schools already do a really good job of reaching the parents in a way that's convenient for them. So that might include a follow-up phone call or scanning the form rather than relying on a student to bring a paper form home. And then having a nurse available, at least in our Vancouver schools, to answer questions parents might have. 

Parents also told us that they would like to know a bit more about what school immunization day will look like. Who will be there to support their child? How will it all go? Just so that they feel reassured about the vaccine experience itself.

For health-care providers, I can't emphasize enough how helpful it is to have school-based nurses, because then those nurses can provide vaccine-related information to parents ahead of time, because this is medical information that teachers and principals are not able to provide. So schools can provide general education. Families very much look up to nurses and physicians for specific advice for their child. So having a school-based vaccine nurse, if possible. 

And otherwise, for health-care providers, remind families about vaccines ahead of time, even if that's not the reason why they're seeing them that day. Because when the consent forms and the vaccine information sheet arrive, parents really don't have a lot of time to decide. It's just one of the many decisions they have to make for their child, you know, in a matter of a couple of days. They might feel rushed to get the consent form back. So I think it's really important for those conversations to happen ahead of time when everyone has had a bit of time to think, ask questions, and then follow up and hopefully consent and agree to have the vaccine by the time the school vaccine day comes around.

Kristen Hovet (11:54)
It was really interesting to me to read that most teachers and students were not aware of online resources like Kids Boost Immunity, which I've had a look at and it's really interesting and has lots of information. And that's a website for educators that offers more than 500 lessons and quizzes developed by teachers in partnership with health professionals to engage students in grades 4 through 12. So what's the best way to promote and integrate such existing educational tools into the classroom?

Hana Mitchell (12:23)
It's an absolutely wonderful resource and has been endorsed as part of our Canadian curriculums for schools that decide to use it. And for children who have used it, they've all told us during our study how much they enjoyed it. [In terms of] our public health responsibility, we know from studies that our teachers in general are extremely supportive of vaccines. They agree that vaccine education is important, but that they need resources to be able to teach about the vaccines in an objective way. 

And so links with public health and schools as part of curriculum planning and letting them know about resources, and then again, where possible, have health-care providers such as nurses come and provide some vaccine education in schools and then using this beautiful curriculum that already exists and encourage the teachers to do so as well. I think it's really important to use schools — so principals and teachers — as a way to deliver vaccine education.

But I don't think we should rely just on teachers to provide that education. I really do think that it needs to be a collaboration between health-care providers and teachers to bring the education into classrooms.

Kristen Hovet (13:28)
Speaking of that collaborative approach, you found strong support for that when it comes to vaccine education in schools, and that involves teachers and principals, parents, nurses, and the students themselves. What are the biggest challenges to this type of approach and how could we make it work?

Hana Mitchell (13:46)
I think it boils down to resources. What we've heard over and over again in our studies is how much teachers, principals, and parents valued having school-based nurses. And unfortunately, with different funding priorities, a lot of schools in BC right now do not have a dedicated school nurse. So they will have a public health nurse or nurses who will come do the vaccines. But these are not nurses that have an ongoing relationship with the school. So I think having those nurses available and strengthening that relationship with public health and schools would really go a long way and kind of take a bit of that responsibility away from the teachers and principals and providing a wonderful information resource. 

And then I think some of it probably depends on the agency and commitment of schools and parent school advisory boards and that ongoing commitment to provide that as part of education. So again, both from a public health level and ministry of education level, and then at the school level, knowing that there are a lot of resources but we need to be creative about how we use them.

Kristen Hovet (14:52)
And speaking of policy changes, if you could make one immediate policy change to improve HPV vaccine education in BC schools, what would it be?

Hana Mitchell (15:05)
I would say make vaccine education a mandatory part of the curriculum using the resources that we already have and linking it to the vaccine immunization programs, which seems so logical. So if you are giving a specific vaccine in Grade 6, why not educate around it ahead of time and provide the information for everyone? While of course the decision to get vaccinated is individual and up to caregivers in Grade 6, the education around vaccines should be universal.

Kristen Hovet (15:34)
Is there anything I haven't asked you about that you'd like to mention?

Hana Mitchell (15:38)
One thing to emphasize is that the study was really well received. Students in particular loved talking about vaccines and asking questions. Even though the study started with us asking questions from students about what do you know about vaccines, it very quickly became a two-way conversation where students said, well, hang on a minute, I actually don't know that. So what do you mean by human papillomavirus? What does it cause? How do we prevent it? How do vaccines work? A lot of curiosity!

This really underscores the importance of having those conversations, not necessarily as part of a study, but as part of general education. And that was by far my favourite part of the study — talking to students and all the interesting conversations that that sparked. I actually did not expect just how many questions and interesting answers I would get from students themselves.

Kristen Hovet (16:28)
That's great! So I guess that almost supports having a special unit on the topic itself.

Hana Mitchell (16:34)
Exactly. Yeah. I almost feel there has to be that kind of formal pillar of education so that information reaches everyone. But then just [offering] a lot of opportunities to be curious and discuss vaccines, and, like you said, spark that conversation among students and then at home or with other trusted adults. You know, using the school-based vaccine programs, not just as a way to give the vaccines, but also as an opportunity for conversation that can then be carried on throughout a lifetime.

Kristen Hovet (17:00)
And a question that we're asking all our guests is, how does your research help children live their best lives?

Hana Mitchell (17:07)
I think staying infection free, so not getting infections that are preventable. And staying out of hospital, not needing to take antibiotics is such a wonderful way of living your best life. And I think research that promotes education and interest in science, right? Not everyone has to become a scientist, but I think it's important for all of us to talk about vaccines.