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Human papillomavirus (HPV) vaccination is included in the Swedish school-based vaccination program, which became gender-neutral in 2020. Although overall coverage is high, sociodemographic disparities persist, and national vaccination targets remain unmet. Delays or missed HPV vaccination opportunities pose a public health risk and may have serious consequences for individual children’s future health. The overarching aim of this thesis was to explore barriers and facilitators to HPV vaccination in the school-based programme, from the perspectives of school nurses and children.

The thesis consists of four studies using both quantitative and qualitative methods. Focus group interviews with school nurses (n = 35) and fifth-grade children (n = 49) explored their perceived challenges and perceptions of HPV vaccination. A cross-sectional questionnaire study among school nurses (n = 344) explored their experiences, knowledge, and attitudes, with comparisons to a 2016 study. Open-ended responses were analysed using the COM-B model to explore behavioural barriers and facilitators to HPV vaccinations. Additionally, a population-based register study assessed socio-demographic factors associated with vaccination uptake in grade 5–6 among boys born in 2009–2011 (n = 190 168).

Findings confirm that school nurses play a central role in promoting vaccine acceptance. Reported barriers included limited confidence in addressing vaccine hesitancy, lack of uniform guidelines to manage hesitancy and ensure children’s participation, time constraints, and insufficient informational materials tailored to diverse family needs. Nurses’ perceptions of their professional responsibilities could either hinder or support their efforts.

Children emphasized the importance of feeling safe, being involved according to their preferences, receiving trusted information, and getting support to manage fear. These needs were not always met, and many lacked awareness of why boys are vaccinated.

Inequities in the vaccination program persist. Immigrant background (boy and/or parent), lower parental education, and lower family income were associated with lower likelihood of boys not receiving the first dose in grades 5–6.

 Strengthening nurses’ Capability, Opportunity, and Motivation through education and training, organizational support, resources, and consistent guidelines may improve equitable vaccine uptake and safeguard children’s right to participate in the vaccination decision. As a result, more children can live longer, healthier lives.