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inconsistent recommendations from healthcare providers, METHODS
and missed clinical opportunities to provide the HPV
vaccine (Daley et al., 2016). National data indicated that Sample
84% of unvaccinated girls had a healthcare encounter The study employed a non-experimental, cross-
where another vaccine other than HPV was administered, sectional design. We conducted a secondary data analysis
meaning that had the HPV series been initiated at these of the School Nurses as Opinion Leaders Regarding the
visits, coverage for ≥1 dose could be as high as 92.6% HPV Vaccine for Youth study, which systematically
(Stokley et al., 2013). There is a public health need to assist sampled (e.g., potential participants were selected by every
healthcare providers in overcoming these barriers to make nth member) 1,443 National Association of School Nurses
every clinical visit an opportunity to strongly recommend (NASN) members. A total of 413 participants completed
and administer the HPV vaccine. the survey between January and February 2013, providing
Given these missed opportunities and need for strong a response rate of 28.6%, which is comparable to other
and consistent recommendations, there is a need to identify online surveys ranging between 27%-56% response rate
and utilize healthcare providers who have frequent and (Kittleson, 1997; Kittleson & Brown, 2005). This study
direct interaction with youth in the age group when was approved by the Institutional Review Board at Texas
vaccination is most needed. The school nurse is an ideal A&M University.
candidate as school nurses have direct and regular contact Measures
with students, parents, and the community. Furthermore,
the school nurse is crucial for bridging health care and Dependent Variables. The dependent variables were
education as they provide services including leadership, school nurses’: (a) HPV and HPV vaccine knowledge, (b)
community/public health, care coordination, and quality attitudes toward HPV and HPV vaccination, (c) perception
improvement (National Association of School Nurses, of their role as an opinion leader for the HPV vaccine, and
2016). (d) professional practice. To assess school nurses’ basic
knowledge about HPV and the vaccine, a knowledge index
School nurses can also be considered opinion leaders with 14 multiple choice items was created from CDC and
as they function across multiple social systems—medical National Institutes of Health (NIH) websites providing
and educational—and have greater contact with change HPV vaccine information and guidelines (CDC, 2013; NIH
agents, such as physicians/clinicians and pharmaceutical 2013). A higher score indicated a higher knowledge about
companies (Rosen & Goodson, 2013). Based on their HPV and the vaccine with a scale range of 0-14 (Cronbach
connections with healthcare professionals, students, alpha = 0.61). To measure school nurses’ attitudes towards
parents, school staff and communities (Council on School HPV, we created 3-item scale (scale range of 3-48;
Health, 2008), school nurses connect with a large social Cronbach alpha = 0.64), and to measure attitudes towards
system that impacts youths’ HPV vaccine uptake. This role the vaccine, we created an 11-item scale (scale range of 11-
allows school nurses to provide vital health information, 176; Cronbach alpha = 0.92). The subscales were
including HPV vaccine information (Lockwood- comprised of a 4-point Likert scale and formed by the
Rayermann & McIntyre, 2009), and sets them in the center linear combination of belief items (e.g., “I believe HPV
of interpersonal communication systems concerning causes major medical problems”) and value items (e.g., “It
school health issues (Rosen & Goodson, 2013). There is is important to me as a medical professional for student to
also evidence that schools employing nurses have fewer avoid major medical problems”) based on the definition of
personal exemptions for vaccines (Salmon et al., 2004) attitudes within the theory of planned behavior (Montano
suggesting that school nurses have the potential to & Kasprzyk, 2008). A higher score for HPV attitudes
influence the parents’ decision to exempt their child from indicated viewing HPV as causing serious health
school required vaccinations. Thus, school nurses can outcomes. A higher score for HPV vaccine attitudes
serve as key opinion leaders regarding the promotion of indicated more positive attitudes towards the vaccine. For
HPV vaccination for youth. We sought to investigate these perception of their role as an opinion leader for the HPV
factors further in order to tailor interventions designed to vaccine, a 3-item scale was created with response options
engage school nurses in HPV vaccine uptake. Specifically, as a 4-point Likert scale (1 = strongly disagree, 4 = strongly
the aim of this study was to investigate whether school agree) also using the linear combination of belief items
nurses’ knowledge, attitudes, perception of role as an (e.g., “I currently see myself as a leader in providing HPV
opinion leader, and professional practice regarding the vaccine information in the school community”) and value
HPV vaccine differ by the grade level, geographic region, items (e.g., “It is important to me as a medical professional
and geographic population they serve. to be a leader in providing HPV vaccine information in the
school community”). Higher scores indicated stronger

2 THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 34, Number 1, 2017