Stakeholders’ perspectives on barriers to and facilitators of school-based HPV vaccination in the context of COVID-19 pandemic-related disruption: a qualitative mixed methods study

Figures & data

Figure 1. A. Khan’s Framework: Access to Care and Prevention.

Table I. Demographic characteristics of stakeholders participants from Initial and follow-up interviews.

Characteristic	Phase 1: n (%)	Phase 2: n (%)	Total: N (%)
Total Number of Stakeholders* Participants	31 (100)	10 (100)	41 (100)
Provider Level Participants	15 (49)	6 (60)	21 (51)
System Level Participants	16 (51)	4 (40)	20 (49)
Professions, Roles, and Positions
Public Health Nurse	7 (22)	2 (20)	9 (21)
Immunization^+ Coordinator & Specialist	5 (16)	1 (10)	6 (14)
Public Health Nursing Clinical Supervisor & Consultant	5 (16)	1 (10)	6 (14)
Front-Line Public Health Nurse	2 (7)	0 (0)	2 (7)
Medical Health Officer	5 (16)	4 (40)	9 (22)
Director, Executive Director & Manager of Primary Healthcare	5 (16)	0 (0)	5 (12)
Clinical Integration, Clinical Standard and Professional Practice: Supervisors, Managers, Directors.	2 (7)	2 (20)	4 (10)
Integrated Service Area under Saskatchewan Health Authority
Saskatoon	2 (7)	1(10)	3 (8)
Regina	6 (19)	2(20)	8 (20)
North	11 (36)	2(20)	13 (31)
Rural	12 (38)	5(50)	17 (41)

*This category includes workers from both: system as well as provider-level..

⁺Immunization Coordinator includes both: those who are Public Health Nurses (PHNs) and assuming the role of immunization.

coordinator and those who are not PHNs.

Table II. Stakeholders’ perception of barriers to and facilitators of HPVV under Theme#1 (information, awareness and Education): sub-themes, factor type (Barrier VS Facilitator), and exemplar quote.

A. Khan’s Analytical Framework (Biopsycho- Social Determinants)	A. Khan’s Analytical Framework (Provider and System Level Determinants of Vaccine Uptake)	Main Theme	Sub Themes	Barrier OR Facilitator	Stakeholders Group	Exemplar Quote
Psyco-Social	Vaccine Attitudes	Information, Awareness and Education	Children & Youth Education	Facilitator	Provider-level	“There is one thing that we used to do years ago, and it kind of went away, and that’s the education piece with the students and in the classroom. As time passed, the public health nurse’s role changed a little within the school. We used to do more, going into the classroom and direct education with students, and I do really feel that that is a loss that we’re not doing that anymore. Lots of vaccines are about trust. Sometimes it doesn’t always work, but if we go in and show our face and say, “This is who I am, I’m not scary. And this is why we’re doing this, and this is why it’s important,” so they understand how vaccines work, and they understand why we’re coming to the school. We’re not just mean nurses coming in to poke them. I think that’s important.” … … .(Provider level Participant, Interview #2)
			Target Channels of Communication Youth Use	Facilitator	System-level	“For this, we have to look at most of the channels of communication that the youth use, and that’s mostly social media. I think we need to put some message on social media, Instagram, or most of the other, TikTok, what they are using, a message there.” … … .(System level Participant, Followup Interview #9)
			Public Health Nurse & Front-Line Staff	Facilitator	Provider-level	“Personally, I am dedicated to educating the vaccine providers, my frontline nurses, to ensure that they have the appropriate, timely resources to address the needs of those students in the schools. I work with school divisions. I’m going to continue to develop those relationships, to explain to them so that they can support the schools, teachers, and their staff on that end so that those public health nurses and those teachers know that it’s a good program for these students and any education that we can provide to those students is an important piece of the success of any immunization program.” … … … .(Provider level Participant, Interview #9)
			Restoring Trust through Education on Public Health & Staff	Facilitator	Provider-level	“I think we need to do better education, of course, whether it’s social media or going to the schools, and I feel the face of the public health nurse needs to be there more. I know we’re busy, but trusting your public health nurse is so big, it really is. It makes me sad when I go to my school, and my kids go to my school, and the kids go, “Ahhh,” because they know needles are coming. I used to go and talk to kids or pick up or whatever; you’re just there; you don’t want to be that scary face. ….(Provider level Participant, Initial Interview#13)
			Parental Awareness and Education	Facilitator	Provider-level	“For parents, too, parents need to know who their public health nurse is, who to call and that we are there; we’re still there and there to help. I think that’s important. Education can always improve. Always, always.”…(Provider level Participant, Interview #4)
			Misconception: HPV is a controversial vaccine	Barrier	Provider-level	“Some common ones that we see are that some parents think we’re giving it too young, like, “why are we giving it now?” Some feel it might encourage sexual activity, and some are concerned about eh safety of the vaccine.” … … . (Provider level Participant, Initial Interview#1)
			Misconception: All vaccines but HPV	Barrier	Provider-level	“There are still a few parents who feel that by immunizing their children for HPV, they are promoting sexual activity. And that they know for a fact that their children are not sexually active. They will not be sexually active until they’re married, and there is no need for this. That is another common belief because they will consent to other vaccines, not HPV. Historically speaking, it is similar to how the hepatitis B vaccine was when it first rolled out and then, more people adjusted to that and started accepting the hep B vaccine as well. The HPV has been, I’d say, slightly lower in people changing their mind.”……….(Provider level Participant, Initial Interview#5)
			Preconception Informed by Religious Belief	Barrier	Provider-level	“For some, for religious reasons, they think abstinence is the best option, and their children will not be sexually active and won’t come in contact with it. And we run into that a little bit too. I think it sometimes has more to do with the fact of their age and that they see it more as a vaccine that’s for a sexual infection as opposed to causing cancer and why we give it so young. Sometimes it’s just a bit of education with them to explain why we do some things. Sometimes parents opt to receive it; some still choose not to.” … … .(Provider level Participant, Initial Interview#8)
			Interactive sessions and Education at all societal levels	Facilitator	Provider-level	“And maybe a way to offer it to parents would be if you educate the teachers and the principals of the school, and then the teachers and the principals could also be the go-between to say, because they’ll know what children probably are not getting any vaccines, including HPV, or even just HPV. And so, if they could say, “You know what,” whether they’re at a teacher conference meeting or the beginning or end of school, or whenever, if a teacher could say to them, “Hey,”- whatever. The teachers have to be careful because they can’t say, “Hey, I know your child’s behind on vaccines.” But if they just said, “Yeah, the public health nurse,” or whomever, “they know a lot of parents have concerns. They can talk to you. You know what, you could talk to them on a Zoom or a phone call or whatever,” and have that face-to-face. I think you have to combat the negative stigma it has. I don’t know how to do that except face-to-face conversations with, like I said, all levels of society, whether it’s a church, early childhood educators, parents, or grandparents. Just the messages of the dangers of HPV and the vaccine’s safety.”…….(Provider level Participant, Initial Interview#6)
			Misconception: HPVV, a sex-related vaccine	Barrier	System-level	“Yes, initially, we did find some religious objections to it because that was probably their misconception or misunderstanding that, in a way, this vaccine would encourage children to get involved in risky sexual behaviour. Some groups thought that giving HPV vaccines is like providing them with a free pass to involve in sexual activity.” … … .(System level Participant, Initial Interview#1)
			HPV-related gender predilection	Barrier	System-level	“Yeah, and when it came out, the focus was on the cervix, right? And what with one vaccine? The one GSK vaccine was even called Cervarix, and it only had 16 and 18 in the component, so it does a bivalent vaccine. So, there is a lot of focus on the cervix, which is just not the right spot for some parents, but now that we have both genders getting it. We talk about head and neck cancers and the increase of those things, and we are trying to prevent all of these cancers, and that should be the story, not, you know, who’s going to have sex.”……(System level Participant, Initial Interview#14)
			Morally Objectionable	Barrier	System-level	“I do think the moral objection concept comes into play in this situation as well, where maybe some parents don’t want to believe their children are approaching that age, or maybe are engaged in sexual activity and either don’t want to believe it or are uncomfortable with that conversation and aren’t sure how to approach it or just don’t want to approach it. So, I think that is also a big part of it.” (System level Participant, Initial Interview#8)
			Target different groups (parents, families, children and youth) to spread Awareness, Provide info and handle Misinformation.	Facilitator	System-level	“I’d really like to see reinvestment again and comprehensive school. Basically, entrenching health more intensively within the school curriculum. You know the immunology vaccinology is a component of their biology courses, and so it ties in nicely. In essence, those kids are getting much more valuable informed consent versus the others, and so that’s what I’d really like to see is that’s just a great example but the whole sweeping concept of taking a look at the curriculum to help strengthen health literacy and line it in with some of these very predictable patterns. We know when to start offering comprehensive sexual education based on biological development during the kids; how do you build that in and again normalize some of that work? And the one we start offering things we know when they’re going to be coming into schools and certainty that the curriculum can align a bit to help build some knowledge and expertise so that they can have that valuable conversation with their families.”…….(System level Participant, Initial Interview#11)
			Target different groups (public health nurses and immunization staff) to a periodic Education	Facilitator	System-level	“And being able to address that and being able to say — as a public health nurse, I think we need to provide the education. We have so much churn right now that I would say that it takes a while. It takes that experienced public health nurse, often not 100%, to really feel confident and so — I don’t mean challenge the parent, but not be afraid of the parents’ questions or if the parent’s like, “Oh, no, I don’t want them to have HPV,” to be able to say to that parent, “Oh, okay, so Hepatitis B is good, so can I ask why you’re not interested in HPV for your child?” Because then that way I know what to address, like what are your questions around it?”……………(System level Participant, Initial Interview#15)
			Vaccine Info Sheet: Amend to address people’s concerns	Facilitator	System-level	Now that I’ve heard, there might be concerns about, you know, the information sheet. If that’s going to contribute to people not providing consent, then definitely those concerns will have to be addressed, and some of them can be addressed in the info sheet. Still, I also think there are specific issues like infertility, right? That’s usually addressed in Q&A, just like we had to do with COVID, right? There were many misconceptions about COVID vaccine, and we addressed those in Q&A documents because you don’t want to leave people in the dark. You want to respond to them if you know the concerns and find the appropriate place to address them, right?”…(System level Participant, Initial Interview#13)
Environmental/ Contextual	Approachability		Target different groups (community health workers) to Education via community outreach	Facilitator	System-level	“I sometimes think we have community health workers in some of our programs. It would be great if we somehow had something in our networks, like a community health worker, particularly for school-age like grade six, where they can reach out to the parents; they may have more capacity to answer parents’ questions. — Maybe if I have a school that has a high rate of, let’s say Ukraine or a high rate of people from Syria, or whatever, that you would have a community health worker with that background that can connect with families and help them with not only our process in Saskatchewan but with any questions they have. Giving them training about vaccine hesitancy. Giving them back the ability to connect with people with a similar background where they feel maybe more comfortable talking to that individual about HPV.”…(System level Participant, Initial Interview#4)
	Ubiquitous Provision		Physicians work as a part of the team	Facilitator	Provider-level	“All health care workers. Every opportunity, physicians, any opportunity. If they know that the children are not vaccinated or need vaccines, education at all times. Answer their questions. In every population, every person trusts a different person, a different healthcare worker. If a public health nurse says it, sometimes they just won’t listen, but if they go to their doctor and the doctor says it, then they’ll listen. Not necessarily the giving of the vaccines, just the education piece. I really think that’s important, especially with vaccines like HPV. I’ve said numerous times trust is big. We really need to work together; we need to be one big team. We all have to be on the same page and understand the science behind vaccines and that they’re important, this is why it’s safe, and this is why we should do it. There are so many different access points.”…….(Provider level Participant, Initial Interview#2)

Table III. Stakeholders’ perception of barriers to and facilitators of HPVV under Theme#2 (vaccine-related logistics): sub-themes, factor type (Barrier VS Facilitator), and exemplar quote.

A. Khan’s Analytical Framework (Biopsychosocial Determinants)	A. Khan’s Analytical Framework (Provider and System Level Determinants of Vaccine Uptake)	Main Theme	Sub Themes	Barrier OR Facilitator	Stakeholders Group	Exemplar Quote
Environmental/ Contextual	Availability and Accommodation	Vaccine- Related Logistics	Vaccine Info Sheet: English as a Second Language	Barrier	Provider-level	“I think people are assuming English as a second language, that they don’t get done, but I find that they are the first ones if we have the information like if we have their immunization history, they’re the first ones to sign their consents and bring them back. And they’re agreeable to getting COVID and flu vaccines when they get their regular infant vaccines when they’re eligible.” … … (Provider level Participant, Initial Interview#10)
			Vaccine Info Sheet: English as a Second Language	Facilitator	Provider-level	The vaccine information sheet, in general, is probably at a great succeeding level. The only thing that might basically is with an increasing number of immigrants, we may need to have the vaccine sheet translated into some other languages that are out there. I know, for example, we had a number of Ukrainian immigrants. And now, there will be a large number again. I would have to get translated before we could get a new form of consent.”………(Provider level Participant, Initial Interview#11).
			School spacing environment and the Confidentiality issues	Barrier	Provider-level	“Sometimes, the schools are struggling for space; they don’t have extra space. There are kids in every corner of the school, so when we get there, sometimes we don’t have a regular space that we use all the time in most schools; we’re kind of just put in a different space every time, we’re working in small rooms or almost like storage closets where we have to set up and maybe don’t have the proper table and enough chairs. When people are getting vaccinated, especially because they do it in from of the whole school, they used to be that they didn’t take them and put them in a different room and vaccinated them. They would just do it in the gym. We’d line them up and just go down the row. I think one of the barriers to that was if you were getting two injections, people knew what you were getting. There was some stigma attached to that, like, “Oh, she’s getting the HPV vaccine. She’s going to be able to go have sex … .(Provider level Participant, Initial Interview#14)
			Under Staffing: A Constant Challenge	Barrier	System-level	“We complain about short staffed and then just keep working, and that’s our worst enemy because the people sitting at the top think, “they don’t have any problems; they can work.” As I said, in the last 20 years, I have seen in my area that public health has been ripped off in every opportunity of staff. Whoever resides in public health, that position is abolished. We are bare bones in public health, and we are still keeping going on. I think the ministry has to be able to see this. An analysis or inventory of public health nurses based on the population. In Saskatchewan, the population is less, but the area is so large; if I’m not wrong, the ministry suggests one public health nurse for a 3,500 population. If you look at this, this is not the case in most of the rural and modern Saskatchewan population”……….(System level Participant, Initial Interview#10)
	Approachability		Vaccine Info Sheet: Hybrid Mode of distributing immunization packages	Facilitator	Provider-level	“Well, my thoughts, probably if you could do a blended method. So, you could do paper or electronic, whatever a parent wanted. Because some parents are really techy, and they know things are coming into their inbox, they’ll be checking and seeing it. “Great, yeah, let’s do that,” get it back, dat-dat-dat, get it back, good. Versus other parents don’t have the capability to be techy, so then they need that paper to come home, and they need to sign it, and they need to get it back. But of course, that means the child has to get it home, and the child has to get it back. But I mean, if it works for that family, great. So, probably a blended method, depending on what the parent, what works best for the parent, that’s probably what I would suggest.”………(Provider level Participant, Initial Interview#2)
			Staffing constraints: difficult Catchup for Missed Opportunities, Work overload and Burnout	Barrier	Provider-level	“The biggest thing’s being missed are we’re short staffed, and when you’re short staffed, you just don’t have the time to do everything as well and as completely as you would. In the past, more time would probably be spent going through our class list. Making sure that everything is more thoroughly up-to-date and more timely. We bring everyone who’s highly delinquent in getting them up to date for any missed opportunities. With our limited resources, sometimes they may have to wait an extra month or two, and we just catch them up when we’re going in to do the school program when we have a number of nurses. It has to do with human resources or public health nurses, and then there could be a somewhat longer delay in catching up with students because we can’t get to them as fast as we would like. From a health side of it, one of our biggest limitations again is human resources. We’re all running very short-staffed. We’re heavily fatigued and highly stressed, having survived COVID. Our sickness rate is through the roof. And doing the schoolwork, making those phone calls, getting the consent, and everything is all limited by not enough public health nurses to do all of the work.”…….(Provider level Participant, Initial Interview#15)
	Appropriateness		Suboptimal Needle Spacing: Multiple Needles For Grade Sixers	Barrier	Provider-level	“I feel that some of these grade six students are being traumatized by having to get four vaccines at once, and we are seeing more students wanting to be immunized in our office. Not in the school because of feeling traumatized, and that’s when you may see that with the first child, or we see that with the second round, and that again has reduced our capacity because that’s an extra time. To immunize these kids in school. Some of them want their parents there. I understand. I understand where the students are coming from because I do think we’ve traumatized some. We have asked that we could maybe split up some of the vaccines. I think when the grade eights are immunized there and given one vaccine, and we have discussed possibly with the ministry that they offer them Menveo, that’s the meningitis vaccine. We immunize with four types of meningitis, and that is one dose. We suggested prior to COVID that it’d be given with the grade eight injection, so they would get two at that point and only get two or three in grade six. I see that as possibly being an improvement. And getting HPV uptake improved because some parents do not provide consent because their kids do not want their other vaccines. So the spacing between the vaccines should be six months. Well, it wasn’t, so it’s not optimal spacing.”….(Provider level Participant, Initial Interview#9)
			Vaccine Info Sheet: Too Wordy & Technical	Barrier	Provider-level	“I just compare that to my own family. My husband’s a farmer. If I handed him my children’s vaccine information sheet, he’d take one glance at it and see how much reading he has to do. He’s a Grade 12 graduate. He’s not a college graduate. He does well with his work but can’t be bothered to read. It’s like, just give me the highlights here. The general public just wants the highlights, so sometimes they’re signing these consents and probably not reading the information sheet. One of the things we already talked about was the consent form and the information being too busy and too difficult to read and complete.” … … .(Provider level Participant, Initial Interview#7)
			Vaccine Info Sheet: Promote HPV Vaccine-Related Cancer Prevention	Barrier		“I think number one, it’s on the information sheet, one of the first couple lines, “it protects against sexually transmitted diseases,” I think that just stops parents. Because, in their mind, my grade six isn’t sexually active. When I finally get to talk with parents and say, “that’s why we do it so early because they’re not sexually active.” Sometimes, they’re a little bit more understanding. I don’t know why; I think that’s what it is. I don’t know, that’s my personal opinion; when they read the information sheets, they see it’s “protect against sexually transmitted disease,” and they’re only in grade six. There’s a barrier there. Maybe that first because once you start mentioning the prevention of cancer, people listen, or parents seem to listen a little bit more because a lot of them didn’t have that opportunity to have this vaccine. And what vaccine is out there that can actually prevent cancer?” … … .(Provider level Participant, Initial Interview#12)
			Lack of Appreciation and Early Retirement	Barrier	Provider-level	“There are two things. It is, yes, of course, funding. To pay the salaries and more money, but then, the other step is just the resource. I’m going to say everyone above me, in general, is not treating healthcare personnel very well, and you have many, many people leaving the healthcare field because of this. Finding the people to put them into the positions will also be a struggle because we do not feel appreciated or valued, and it is a huge factor in the welfare, availability, and functioning of healthcare workers as we see them today.”(Provider level Participant, Initial Interview#6)
			Vaccine Info Sheet: Mode of distributing immunization packages & Privacy Issues	Barrier	System-level	“Yeah, I think when you’re looking at improvement, you need to look at barriers. And for me, the big thing that applies to all vaccines we provide schools is definitely the consent process. We need to think about how we can make it easier for parents; how can we make sure that parents receive that request and they send it back? I agree with some parents that hard copies are going to work, but for other parents, electronic copies are going to work, but then also the question about where the electronic copy comes from SHA, schools directly, you know, the whole privacy issue, so consent is at the top of the list. … …(System level Participant, Initial Interview#2)
	Acceptability		Linkage of School Data System and Panorama	Facilitator	System-level	“Yeah, and that’s where I, my sweeping statements from earlier of the assigned PHN, reach out to the schools, which they call; I have no idea. Who’s their connection at the school? I don’t know. How they go through that conversation of exchanging information, I don’t know. We’re working towards a process where there should be a push directly from the school data systems to Panorama. That’s really what we want. We want to ensure that because, quite often, what the schools have registered is quite different from what the actual school looks like when you immunize. So, although we’ll send a list, the school’s okay school started; these are the kids we have registered in grades six and eight, and it’s different by the time they go in. There are a lot of kids who have moved in or moved out, which makes the day quite delayed because there are surprises. And so, to be able to get, yeah, so that one was always a bit of a challenge.”…(System level Participant, Initial Interview#12)
			Staffing Issues: A Political Barrier	Barrier	Provider-level	“Ideally, it would be great to think that opportunity is going to present. If you want to know how we feel in reality, it’s the exact opposite. We feel that there is an ongoing plan to devolve public health in general. We feel that they are trying to get rid of public health. We function in the long term. The vaccine you see a benefit of it in twenty years. All of your politicians are full in power, running the money; their terms are four years. They want to be able to promote what they have managed to accomplish in acute care because they can see immediate results. How we feel as public health staff is that they are attempting to get rid of us. They are promoting physicians and pharmacists to give more and more vaccines. I have no problem stating factually that we do a far superior job of vaccines. Whole chain administration, documentation, you name it. We do so much better at it as compared to pharmacists and physicians. That is what we do. They do it off the side of their desks, and you can tell. You could probably also tell I’m a little angry about this piece.” … .(Provider level Participant, Initial Interview#12)
			HPV vaccine to a single dose	Facilitator	System-level	“I’m really excited about the idea of a single dose. I think that’s even in the Hep-B stages too, and part of the reason is then you have two opportunities, right? So, if kiddo weren’t around for the first visit, they’d be behind on their B, but they’ll be able to catch them up on their second dose, I mean their full dose of HPV. So, they only go into the schools once, which means if your kid happens to be sick that day, truant, or have whatever reason that they’re not present, the only opportunity for them to get back on track is through their family who would have to seek that service through a clinic, which then means it’s client-driven instead of being a push to the client.” “Now, the school kids will get two doses, right? If they’re outside of that age range, they will need three doses; if they are immunocompromised, they’ll need three doses. But in the future, we know now that one dose is as effective as three doses to prevent all those warts and cancer. We haven’t started to do that yet, but we are waiting for the NACI statement. At some point, NACI will put out their statement saying we can likely offer one dose as the equivalent of three doses. That will take time, maybe a couple of months or six months. At some point, that will happen because there are so many good studies and WHO also recommends only one dose of HPV vaccination for feasibility, and equal protection, compared to three doses. Then, why not one dose moving forwards in the future? Now, that’s just for information. The status is still the same, but at some point, that will happen.”…(System level Participant, Initial Interview#8)
	Cost		HPV Vaccine Cost: An issue	Barrier	System-level	“Right, and I know the cost came up; I just remember hearing that from a parent. Her child was a; I can’t remember the exact dates, but there was a cutoff date where it was free, but they were born before that, then they had to pay, and their parent was willing to pay but wanted their child just to be forthcoming of when they were reading to need it. That was a bit of an awkward conversation because it came down to, we know we need it, but we also have to pay for it, so we have billed them before then.”………(System level Participant, Initial Interview#15)
			HPV Vaccine Cost: Age Cap for HPVV Eligibility	Facilitator	System-level	“Yet, I do think we would be able to justify promoting the HPV vaccine a lot longer and include other age groups and other risk factors. Right, now, in Saskatchewan, we have an age limit to get the HPV vaccine for free, but what if you’re immuno-compromised, which I think is terrific, regardless of your birth year, that is from nine to 26 still though. It does capture all people. That’s really good, but we don’t cover men who have sex with men. We only cover males if they’re healthy and born in 2006 or later. But again, I think we also need to target our men who have sex with men as a high-risk category. In any case, it would be great if it was like Hep-B, where once you qualify, you always qualify.”…(System level Participant, Followup Interview#10)

Table IV. COVID-19 pandemic impact on school-based HPV immunization programme: categories, themes and exemplar quote.

The COVID-19 Pandemic Impact on School-Based HPV Immunization Program
Key Themes	Sub-themes	Type of Impact	Exemplar Quote
Resource Scarcity	More staff, time, resources, and organization/planning required	Negative	“From a health side of it, one of our biggest limitations again is human resources. We’re all running very short-staffed. We’re heavily fatigued and highly stressed having survived COVID. Our sickness rate is through the roof, and we’ve had many job vacancies. Just trying to get into the schools on a regular, consistent basis. And doing the schoolwork making those phone calls, getting the consents and everything is all limited by not enough public health nurses to do all of the work. We didn’t get any more staff; actually, we lost staff because staff were pulled to run 811, COVID swabbing and COVID vaccinations. And we didn’t have the space to immunize 5 000 kids three times in our baby clinics because people were still having babies and babies still needed all those appointments. We tripled and quadrupled our workload with absolutely no help from our upper management in terms of hiring casuals or providing support.”….(Provider level Participant, Initial Interview#6)
	More time to deal with more kids overdue for HPVV and other vaccines, so more needles at a time	Negative	“We don’t have time necessarily to track down some of those students or their parents for consent. For private. And they have three classrooms now to deal with, not just one. Sheer numbers have increased. That has not really enhanced our ability to get these kids immunized. It’s put up a wider, bigger barrier. The other thing is that we are still working with COVID at this point. And we are still catching up on other programs. Capacity, there is minimal capacity before, and now our capacity has decreased even more.”….(Provider level Participant, Initial Interview#10)
	More human resources are required to implement different programs due to varying local capacities.	Negative	“If we are offering COVID vaccine to that school-age population, that we’re doing that at a totally different time than we’re offering those school-based programs- the HPV, Hep-B, meningococcal. We’re really working hard to separate that programming even though it takes a lot of human resources to be able to implement two different programs primarily at the same time. Once those COVID vaccines started to run, we’ve been consistently running clinics for those vaccines, which is taking up a lot of our time, and a lot of our human resources and in rural, we do not have a COVID-19 immunization team separate than the public health nurses. I don’t think some areas understand that it is the same nurses that are doing school programming, COVID programming, all the Child Health Clinic programming, and all the influenza programming. We don’t have separate teams to do that. We are depending on the same nurses, the same FTE, to do it all. Just that as a system, how we approached administering it was inconsistent based on local ability to either complete the work or not based on the pandemic. And that is because the pandemic impacted local areas of the province differently at any given time.”……(Provider level Participant, Initial Interview#7)
	Provider Fatigue and Burnout	Negative	“Resources. Basically, it feels like our workload has doubled. Because we are the main suppliers of the COVID vaccine to the public. That was put on us and our staff to deliver. During the heavy part of it, we were offered and did have some additional immunizers to help us do all that. Currently, those have all been removed and taken away. We are back down to our original staff. And we are still expected to deliver the new program, the COVID program, our school program, our child health conferences. Everything is to go forwards with our original staff. Hence, fatigue and stress, increase in illness, we’re exhausted.”…(Provider level Participant, Initial Interview#4)
	Lack of Recognition	Negative	“But I would like to think that for most people, hopefully, the health system and Public Health and the vaccines that we provide to the kids and the COVID vaccines that were developed so quickly and that everyone tried to get into arms so quickly. Hopefully, was a good news story. I know Public Health. Everyone knows who’s Public Health during a crisis. It’s the story of SARS and everything. It needs a good crisis to make people aware of Public Health, but then, it fades away pretty quickly.”…(System level Participant, Followup Interview#4)
	Staff reallocation and work redistribution	Negative	Also, many people were focused on the COVID vaccine. So, not just the HPV vaccine but also other immunization coverages were impacted. The demand was there, but the demand for the workforce was in other places. Healthcare workers and public health nurses had to be deployed in other sectors, so that has definitely had an impact … (System level Participant, Initial Interview#6)
	Testing and contact tracing for other infections halted: Outbreak of other infections, e.g., syphilis.	Negative	“STIs were not tested, and we did not have time to follow up the cases and the contacts, so we have now too many cases of syphilis and other STIs that were not tested, and they spread. So, that’s another side of looking at it, if something happens in the future, how the public health staff will be able to carry on their local, routine services, Communicable Disease Control, Immunization, the Public Health Inspectors carrying on their public health visits, inspections and everything. So much got lost, not only immunization; our immunization rates have dropped, syphilis is out of control, HIV. We’ve had significant increases in cases of HIV, it’s appalling, actually.”…(System level Participant, Initial Interview#15)
	Difficult catchup due to a huge backlog	Negative	“We did actually have to shut our school-based programming down for a year which definitely put us behind. Last year, last spring, we made a big push to try to get caught up on our school-based programming. So, right now, this year, we are doing grades 6, 7, 8, and a little bit of grade 9. Just to try and catch up for that year, year and a half, that we did miss people in getting the series completed. We had kids fall through the crack, I’ll say, with moving and being transient and just missing them during those school years. We had a larger portion of students that were not attending the class that were doing online schooling. And so, we have such a backlog in our public health office visits that we weren’t able to do school-based out of those clinics, so I think it’s just really that backlog that we’re still trying to catch up. We’re a lot closer than we were last year, but we’re still playing catch up right now”……(System level Participant, Initial Interview#7)
	Vaccine Equipment Handling & Storage	Negative	“One of the barriers is that in our offices, we are storing a lot more needle supply and alcohol swabs, all those tools that we use and some of those are for mass clinics and some of them are for schools. One of the barriers is that we’re storing both of them in our offices and lots of time there is a lot of supplies that we’re are trying to climb over and figure out which one is going to the school and which one is going to the mass clinic. That is a little bit of a barrier, is being able to store and handle all the equipment we need.”….(Provider level Participant, Initial Interview#8)
Vaccine Skepticism	More anti-vaxers: More vaccine hesitancy in parents and more anxious kids	Negative	“I know the nurses that they’re finding they’re dealing with much more high anxiety kids. They are having to take more time with the children in distraction or stress-reducing activities for immunization. They are also noticing more vaccine hesitancy, parents wanting their children immunized at the offices versus the school. And nurses find there is more hesitancy about vaccines. Since the uproar with the COVID-19 vaccines and some of the conspiracy theories that have been out there, and some parents are applying that to all vaccines.”……(Provider level Participant, Initial Interview#11)
	More refusal of vaccines	Negative	“And then, we could see is more like public skepticism with regards to public health since COVID. Increased misinformation on social media leading to vaccine hesitancy. We definitely have seen some parents who I feel would have accepted the vaccines before deciding to decline them now. Some parents stopped immunizing completely, once COVID vaccines came out, they lost a lot of trust in the system. “Well, if they’re forcing COVID vaccine on us are they are forcing this? why?” You know, so they had a lot more questions. We did have some people stop immunizing completely to everything, not just HPV.”….(Provider level Participant, Initial Interview#2)
	More public health clinic appointments as opposed to school-based immunization	Negative	“I don’t know if this is just a local nuance, we’re also seeing a lot more parents requesting their children to be immunize at the office. We have actually increased the number of clinic appointments available because we are finding now, too, I think partially due to the mistrust, more families are preferring to bring their child to clinic rather than having them immunized in the school. I don’t know if that’s still because they worry that if the parent isn’t with them that we will secretly stab them with COVID vaccine, but we are seeing more families asking if they can book their child in.”….(Provider level Participant, Initial Interview#4)
	Relationship between school staff and PHNs challenged: Hesitant resumption of former school-based needle program.	Negative	“Do you know what, I would say pre-COVID, probably a lot better. I think the relationship was, well, number one, the longer that nurse is in that school, the better that relationship is with that school. I 100% believe that you need, whether it be with the client or whether it be with another system like the school, you need to develop that relationship with that school. That relationship is very fragile, so it has to develop not only from the director level, the ED levels, and the school board levels, and it has to develop from up there down. We work hard at developing that relationship so we’re supportive of each other. But we’re guests going into that school, but we still need to be able to do your programs. Obviously, COVID put a lot of barriers to that, our school immunization program and even now, schools, I think, are mostly over their reluctance to have people coming into their schools, but that did impose quite a significant barrier during COVID for sure.”….(Provider level Participant, Initial Interview#13)
	Trust Issues: Mistrust to both Public Health and Health Systems	Negative	“Every school is a challenge for a different reason. It’s too hard of a question to ask because the principle of public health, you’re taking it down to the very basic immunization, which is a task. The trust that the public has in us has been — lost, we lost trust with the public with COVID and that has spilled over into regular immunizations. That trust we have; it isn’t there as much as it used to be. It’ll come back, and it’s going to take a couple of years.”….(System level Participant, Initial Interview#3)
The COVID-19 Pandemic: An Example	COVID as an example of HPVV Advertisement: Provincial Education or Awareness Campaign	Positive	“Immunization as a whole, coming out of the pandemic, immunization became a much more controversial topic maybe during the pandemic, or just there’s more awareness around the topic of immunization coming out of the pandemic, and so, HPV as well as immunization as a whole we’ve really probably need some of those public campaigns and some of that messaging that’s very in the public but with correct information. Not forceful information but supportive information. And with the HPV vaccine. Just education and really kind of visually appealing kind of campaigns and a bit more understanding about that particular immunization and just maybe revisiting some of the early campaigns that were done. Through education, we need to let them know what it means, and it doesn’t have to do anything with their sexual activities, just a preventive program down the line. When they become sexually active, they could be exposed to a virus that could ultimately cause cervical cancer.”….(System level Participant, Initial Interview#11)
	Technology can help us	Positive	“I think on the flip side, there’s people that are more in tune with immunizations, right? Because of what we’ve gone through. So, I think our teams have seen a different way of how we can do things differently, how technology can help us. How we can more modernize population in public health services in a different way using different technologies. So, you know, and also using different scopes of practice to enhance our human resource capacities. So, I think we’ve learned a lot through COVID and can definitely take those things forward.”….(System level Participant, Initial Interview#9)
	Practise of Infection Control Guidelines: Positive Behaviour Impact	Positive	“I think infection control, cause that’s something that was a little bit different compared to pre-COVID is more attention to either the mask, how important is handwashing, and disinfecting before and after. I think those things are a lesson learned going in now, compared to before the infection control guidelines. There’s a lot of safety practices that became second nature with the covid clinics, which I think were described as the best practices in schools that maybe weren’t always being executed that we can bring forward.”……(System level Participant, Initial Interview#6).
	COVID-Vaccine Related Success: Vaccine Hesitant turned Vaccine Inclined	Positive	“I think on the flip side, there are people that are more in tune with immunizations, right? Because of what we’ve gone through. So, maybe people that were hesitant before are more inclined, so I think that’s a positive. I think our teams have seen a different way of how we can do things differently, and how technology can help us. How we can more modernize the population in public health services in a different way using different technologies. So, you know, and also using different scopes of practice to enhance our human resource capacities. So, I think we’ve learned a lot through COVID and can definitely take those things forward.”…….(System level Participant, Initial Interview#12)
	Mode of Consent Changed to accommodate COVID-19-related restrictions	Positive	“During COVID-19, because we weren’t going into the schools, or they were closed or whatever, I actually had a lot come in prior to school starting, or they would come to my office. I, fortunately, was kept up with all my school immunizations. I didn’t fall behind, as I know some schools did. The consent process, if they were brought into the clinic, I discussed it with the parent at that time and they signed, and I just did right in my office. Then when it was lifted, and we could go back into the schools, then I would go, then the information was just sent out as regular letters or the consent form, the information was just sent out with the child and then returned back to the school.”…….(Provider level Participant, Initial Interview#6)

^{Negative: Impeded HPVV uptake. Positive: likely enhanced HPVV uptake}.

Table V. Current mandate across Saskatchewan to reach HPV vaccine coverage targets: categories, themes and exemplar quote.

Current Mandate Across Saskatchewan to Reach HPV Vaccine Coverage Targets
Themes	Sub-themes	Explanation	Exemplar Quote
Alternate Vaccine Clinics	Mass Clinics/Community Clinics	No school-based flu or covid clinics.	“So, we will have to plan more school-based clinics for these children, and we are also, for the other vaccines, which are not school age vaccines, the flu and the covid. We are encouraging parents to send their children to the mass clinics that we are organizing in the communities. That’s another issue. We cannot go into the school to offer flu clinics or covid clinics. As I said, if we leave everything else and put all of our efforts into school-based immunization, we will still need a lot of time to catch up for those schools because, as I said, we don’t have enough staff to immunize all the children, who are the three categories that we had mentioned: the children who have already missed the vaccine, children who are due now, and the children who will become due in the due process in the coming months.”….(Provider level Participant, Initial Interview#2)
	Alternate Vaccine Clinics: Additional and Extended-Hour Clinics	Tracking age groups missed & putting together corrective action plans.	“Yeah, both offering additional clinics at the public health offices but also making sure we kind of know what age groups were missed in the last couple of years or maybe haven’t had that opportunity. Our public health nurses do have a very good tracking mechanism to kind of know what schools they went into and where they have not and just offering additional clinics within the schools. We had talked about once we get through flu season even trying just to book some additional casual resources to catch up both on our syphilis work and also to address some of our vaccine work and corrective action plans.” … .(System level Participant, Initial Interview#6)
	Drive Through Immunization	School-based Immunization turned into Drive through Immunization	“We had to change things up very, very quickly. When the pandemic first hit in March of 2020, we already had our plans to go into school in April, but then we couldn’t do that. We actually quickly flipped, and we set up a drive-thru immunization — we were able to get one of our arenas and it worked really well, actually. It is something that I think we should maybe try to do again in the future because — again, the kids have to come to us, they have to have a vehicle. We had some who biked, but again, you generally need to have a parent or somebody to bring you.”…….(Provider level Participant, Initial Interview#11)
	More Trips to School to CatchUp for Missed Opportunity	Playing Catchup: More Grades to Track, More Trips to School and More Clinic Appointments	“When we went into schools — so normally, we’re doing grade sixes and grade eights and this year each nurse had to check their grade six and seven, grade eight and grade nine classrooms. We were going into the grade above to try and catch anybody who we missed. We’re doing more trips to schools, maybe, than what we did before to try and do those catch ups. We have actually increased the number of clinic appointments available because we are finding now, too, I think partially due to the mistrust, more families are preferring to bring their child to clinic rather than having them immunized in the school. I don’t know if that’s still because they worry that if the parent isn’t with them that we will secretly stab them with COVID vaccine, but we are seeing more families asking if they can book their child in. So, we’ve increased appointments that way.”…(Provider level Participant, Initial Interview#4)
	Strategic CatchUp: Classroom-focused vs grade-focused	Playing Catchup: More Nurses, More Trips to School and Mass Clinics	“A lot of places I think are doing each classroom now instead of just focusing on the suggested Grade 1,6, and 8. So Grade 1 to 12, and going in one to two times per month to try and catch these places up. Other places are utilizing … like in the bigger centres, they’re utilizing two to four public health nurses going in as a group. And playing catch up that way. Trying to do mass clinic with some schools that are very far behind. How successful has this been, I don’t know. To be honest, I’d actually have to ask that question and I’m not measuring the success for that as well at this point.”(System level Participant, Initial Interview#7)
	Blitz then Strategic	What works for a certain area works for them.	“Yes. I described the one where we did have the blitz. I think that was summer 2021, and then beyond that, I think it’s, each school trying to, and each team that serves that school is trying to be creative. So, looking to see how they can decoy more days, right? Larger teams on the same day or what works for that particular school because they no longer just going in to immunize sixes and eights now, they’re going in to immunize six to eight, nine, ten, eleven. And so, the number of those need to be immunized is much larger than the provider pool is, or at least smaller if we were talking about the additional other asks around delivery. So, it’s very team. That team to that school, and trying to find a path forward. Yeah, so right now we’re pushing hard to get things to be a little bit more strategic, but I’d say that’s the approach at the moment as we transition.”.(Provider level Participant, Initial Interview#13)
	Hybrid Types of Immunization Clinics	To Reach a Mass population, different clinic types were set up	“We can be very efficient with mass communication, immunization strategies. We can use technology to help with consents with booking with pre-booking, appointments to make it very convenient for the end user. We could do hybrid types of immunization clinics. We can do drive through, drop-in, school-based, center-based, physician-based, pharmacy-based immunizations to reach a mass population.”(System level Participant, Initial Interview#9)
	Inside School, Vaccination Connect And Outside School Vaccination Connect	Getting the target audience on board using different access points	“I know I’ll use Linus and they do phone calls; they try to catch them and schedule them when they go into their school visits. So, those would be their main two strategies is to try to connect with them outside of school and arrange a follow-up, and, or connect with those that have missed whether in school vaccinating the current grouping.” … …(Provider level Participant, Initial Interview#8)
Anomaly	COVID-19 did not impact	We kept up with immunization uptake	“I know that we’re a little bit of an anomaly, as certainly in rural health because we did make the decision that we were not going to suspend these school-based immunizations during the pandemic. We actually didn’t have any of them that were missed, so we don’t feel that we have to catch up. Part of our rational for that was, we said, “We don’t want to come out of this pandemic only to have children —” I mean, HPV isn’t going to be a pandemic or an epidemic, but we didn’t want to come out of the pandemic with an epidemic of measles or an epidemic of mumps or an epidemic of whatever because we didn’t keep up with these. So, we just felt that that was an important priority. As far as the COVID-19 having an impact on us keeping up with those immunizations, that is not the case here.”…..(System level Participant, Initial Interview#12)

Table VI. Lessons learnt during the COVID-19 pandemic: themes, sub-themes, and exemplar quote.

Themes	Sub-themes	Explanation	Exemplar Quote
Gaps in Public Health Systems Planning and Operationalization	Lack of Contingency Plan	We should have a Plan B	“A lesson learned is that first of all, we should have a plan B, so that our children, not only school-based immunization, but the childhood immunizations don’t suffer if we are facing something like covid in the future. We should have a plan B and we should have enough staff or personnel that if something like covid happens in the future, the child immunization and the school-based immunization do not suffer. I don’t know how that will be accomplished, as we did through covid, most of the covid or pandemic related work is taken up by other public health staff and the public health staff could go carry on their local work, because it’s not only the vaccination. We are probably in a crisis situation, probably with syphilis and other STIs because we didn’t have the time because covid testing pressure other STIs were not tested and we did not have time to follow up the cases and the contacts, so we have now too many cases of syphilis and other STIs that were not tested and they spread. So, that’s another side of looking at it, if something happens in the future, how the public health staff will be able to carry on their local, their routine services?”…….(System level Participant, Initial Interview#1)
	Fragile Public Health System	Prioritize COVID over everything or anything.	“Though another lesson learned is that how fragile our current public health system is. And its resources. That it was unfortunate throughout that period that we had to prioritize COVID and COVID vaccine over school-based immunization because it was really ethically difficult. For both the public health staff and the administration staff to have to make those choices and prioritize one thing over another that are equally important.”…..(System level Participant, Initial Interview#10)
	Get it at The First Opportunity.	If you do not optimally utilize the first opportunity, you might never get it again.	“Get it at the very first opportunity, I guess. Like dont you know, be prepared going in. Make sure you have all your work done before going in, because you might not get another opportunity going back. Right. Like there are some kids, cause some kids just fall. There are just three or four kids before we got to see them and if we’re not ready then you’re not getting that kid immunized cause they’re there so rarely.”…..(System level Participant, Initial Interview#8)
	Lack of Working Policy Around Mature Minor	A way around when the consent form is not returned	“Secondly, the whole mature minor piece that came more to the forefront during COVID would really like that to be further discussed and apply it more liberally in grade 8. If kids do not bring their content forms back. Yeah, that’s what I can think of what we’ve learned from COVID.”…..(System level Participant, Initial Interview#15)
	Gaps in Public Health Personnel Planning	Public Health Personnel Planning: Only A Wishful Thinking	“Covid has revealed that we are lacking in public health personnel planning. I usually say we don’t even have the critical mass of the public health staff to provide routine services because of the shortage of so many public health nurses. On top of that, if something like covid comes, the staff is so overworked that nothing can be done. I usually say that we are our worst enemies in public health because we keep on working. We don’t complain; we just keep on working, we get together and complaint to each other and then just resume work … The staff, the public health nurses, who mainly provide school-age immunization were too busy doing covid-related activities, not only vaccination but case and contact follow-up, they were so busy that covid was the main barrier in the last two years. It has overshadowed all the other barriers. It’s also made the issue of staff shortage, and human resource shortage because we did not have enough personnel to do covid and school immunization at the same time. So, lessoned learned: go with the flow. I don’t know. There was nothing we could have done anyway. In a perfect world, I think what I would have liked to see was the key programs and that would have meant extra public health nurses to cover the regular programming while everybody else focus on the pandemic. But that never did happen anyway, so that’s wishful thinking.”….(System level Participant, Initial Interview#1)
	Mistrust of Public Health and Health Systems	COVID Vaccine Mandate and some people’s Reaction: You are not telling me what to do	“Again, the next big one was the trust/mistrust with the public health system, or the health system in general. Lessons for me though, too, not with regards to students at all is that, us as a program are very flexible. When we talked to people trying to get consents like you get the idea that they feel like the government is trying to control them. We’ve heard a few things that now they’re thinking that HPV vaccine is a new vaccine, so they don’t trust it. It’s something they were familiar with before, like the old diphtheria and tetanus and stuff that families are used to. So, there’s more distrust in the HPV vaccine. Everything maybe has to do with the policy- the vaccine passport, they have to have been vaccinated to go to the restaurant, to go to the plane. Some other public health mandate came in because those people may be didn’t like how the way how that happened. They wanted to freedom. They want it to be not at all you need a COVID vaccination or not. It’s small population of those who are saying, “You are not telling me what to do so if you are telling me then I am not even going to do what I want, what I was supposed to do.” I think it’s mainly came out of those vaccine passports, vaccine mandates. The mandate made them mad.” ….(Provider level Participant, Initial Interview#12)
	Targeted Strategies Based on Local Ability and Variation	A quasi-strategic way to work on the catch-up cohorts at the network level based on the variation	“I think these trying to look for any window of opportunity in a quasi-strategic way to work on their catch up cohorts. And that’s very much driven at the network level, trying to do it as close to each school and each cohort as possible because we have a lot of variability, and the schools, right. Got some very privileged schools where that parents are upset that we can’t get them in right away to the other clinics, the ones where families are really appreciate a school-based program because getting to the clinics isn’t there so they’d really like to see that kind of model, and they’ve got others where there’s a lot of complex conversations around immunizations overall. So, I’d say the response on this one is it’s, we’re trying to develop strategies as close to the particular cohort who’s behind as possible, and that’s a lot when we have so many schools.”………..(System level Participant, Initial Interview#9)
	Health Promotion Neglected: Long-Term Plan Needed	Health Promotion Already an Uphill Battle	“People are just over public health. They don’t want any more immunizations; they don’t want to even talk about how we’ve lost a lot of our health promotion thanks to COVID because everybody had to focus on the COVID response and the whole concept of response is exact opposite of what health promotion is. We have not been able to do health promotion for the last couple years. It was already on a lesser level of intensity, lesser level of involvement within the health care system overall, there isn’t a ton of dollars attached to health promotion, so we don’t have the amount of stuff, we don’t even have nursing resources, so it was already an uphill battle and then taking those resources and putting it to the COVID response has resulted in a lack of health promotion because of having to deal with COVID.”(System level Participant, Initial Interview#13)
	Long-Term Consequences of Temporary Policy	Pandemic Emergency Policy Proved: A Misfit Policy	“I think one of the lessons learned, again, is COVID-19 around the school-based immunization programming was, it was a policy that came from the ministry that parents had to be present if the student was going to receive COVID-19 vaccine in the school, which created all kinds of barriers for those people who couldn’t take time off work, couldn’t be at the school, there was some who didn’t have transportation. All kinds of reasons. And that’s not the way that we’ve ever done it before, so I think that that has created a negative consequence and it has a created a bit of mistrust, which is very unfortunate.”….(System level Participant, Initial Interview#15)
	Renewed Emphasis and Need for Patient-Centered Approach	Consent Sorting is a Nightmare	“Oh, consent sorting is a nightmare. It’s one of the most time-consuming problematic issues that comes up is about how, as we talked about earlier, how disruptive that is. How the schools loathe it, the families loathe it, it’s ridden with the ability for consent to get lost, it doesn’t allow—it depends on literacy, it depends on time availability, familiarity. It’s certainly problematic and it would be really nice if we could find a way that was more client centered but also a less of a burden to both the public health side as well as the education side.”(Problem level Participant, Initial Interview#9)