Improving School Vaccinations for Adolescents With Intellectual and Developmental Disabilities: A Person‐Centred Approach

ABSTRACT

Aims

This article investigates school vaccination for adolescents with intellectual and developmental disability through the lens of person‐centred care principles.

Design

This is a theoretical framework analysis in which qualitative interview data were mapped to the principles of a Person‐Centred Practice Framework.

Data Sources

Data were drawn from Vax4Health, an empirical study that aims to improve vaccination uptake and experiences for adolescents with disabilities.

Methods

Our four‐step process included: identifying elements of the school vaccination programme that relate to the Framework domains; mapping programme capacities and challenges by each domain; identifying key factors influencing person‐centredness; and synthesising these key influencing factors into three themes.

Results

We extrapolated three themes: (1) Parents and students expressed strong support for the programme, but there is potential to enhance their participation in vaccination decision‐making processes. (2) Nurses bring high levels of motivation, clinical experience, empathy and creativity to vaccinate students, but opportunities remain to enhance disability‐specific training and knowledge of individual students' needs. (3) Special schools are committed to supporting families and facilitating the programme, but limited resourcing and unclear responsibilities present challenges that need addressing. We discuss how these themes relate to the five domains of the Framework. Key considerations for vaccination programme improvement towards a more person‐centred approach are highlighted.

Conclusion

Applying the Framework to the findings of the Vax4Health study identified a range of opportunities to improve person‐centred school‐based vaccination for adolescents with IDD. Future research could involve engagement with all stakeholders to co‐design interventions aimed at applying person‐centred care principles to vaccinating students with IDD.

Impact

The findings from this analysis could be used to inform future implementation research into person‐centred approaches to school vaccination aiming for positive outcomes for adolescents with IDD, their families and schools and health professionals.

Summary Statement

What is already known

• Adolescents with intellectual and developmental disabilities (IDD) have significantly lower vaccination rates than their peers and face unique barriers in school‐based vaccination programmes.

• Person‐centred care principles are widely recognised for improving healthcare quality and equity but have not been implemented in vaccinating people with IDD.

• Parental lack of accessible, tailored vaccination information, students' communication difficulties and needle anxiety and nurses' lack of information about individual students' needs are common obstacles preventing adolescent children with IDD from receiving vital vaccinations.

What this paper adds

• Parents and students strongly support school vaccination but have limited opportunities for shared decision‐making and individualised preparation.

• Nurses demonstrate high motivation and empathy but lack disability‐specific skills and confidence in managing individual students' needs.

• Special schools are committed to facilitating vaccination but face unclear responsibilities and inadequate resourcing.

Implications for practice/policy

• Embed shared decision‐making processes and accessible, disability‐specific information for families and students in vaccination protocols.

• Invest in specialist training and organisational supports for immunisation nurses to strengthen person‐centred vaccine delivery.

• Formalise and resource schools' roles in vaccination programmes through clear policy frameworks and interdepartmental collaboration.

1. Introduction

Person‐centred care is a well‐established concept in nursing and healthcare discourse (McCormack et al. ²⁰¹⁵). At its core, it aims to improve the way health systems respond to the needs of all interested parties in a humanistic and holistic manner, where the individual who needs care is respected as a whole person with multidimensional needs (World Health Organization ²⁰⁰⁷). This involves treating all people involved in the care process as individuals, respecting their rights as human beings, building mutual trust and understanding, developing therapeutic relationships and making shared decisions (McCance and McCormack ²⁰²³). It is recognised; however, that sustaining the provision of this kind of care is dependent on the existence of a person‐centred culture where the same person‐centred values are bestowed upon staff who provide this care (Coulter and Oldham 2016).

International research shows that adolescents with intellectual and developmental disability (IDD) in special schools receive significantly fewer vaccinations than the general population: 53%–66% versus 73%–82% (O'Neill et al. ^2019a; Vujovich‐Dunn et al. ^{2022, 2021}; Sisnowski et al. ²⁰²¹; O'Neill, Elia, and Perrett ²⁰¹⁹; O'Neill et al. ²⁰²⁰; Fisher et al. ²⁰¹³; Rowe et al. ²⁰¹⁷; Tiley et al. ²⁰¹⁹; UNICEF ²⁰²²). There is limited understanding of the barriers to vaccine uptake among this cohort in school‐based programmes and how to best address them to maximise equity and achieve higher coverage (Tuckerman et al. 2024; Carter, Klinner, et al. ²⁰²⁴). Some studies suggest communication barriers hinder healthcare providers from fully understanding and meeting their needs (Alsamawi 2023; Roscigno ²⁰¹³; Dunn et al. ²⁰²³). Other studies indicate that adolescents with IDD frequently experience vaccination anxiety and/or medical/needle trauma (Du et al. 2008; WHO ²⁰¹⁷; Orenius et al. ²⁰¹⁸; Baxter et al. ²⁰¹⁷; Christou‐Ergos et al. ²⁰²³). Person‐centred care may have the potential to address these issues at the root by respecting students as agents of their body and mind, considering their individual special needs and involving them and their parents or carers in the preparation and provision of the vaccination service (Carter, Klinner, et al. ²⁰²⁴; Klinner et al. ²⁰²⁵).

A variety of person‐centred care models and frameworks have been discussed and applied internationally (e.g., Santana et al. ²⁰¹⁸; Leplege et al. ²⁰⁰⁷; Ekman et al. ²⁰¹¹; Harding et al. ²⁰¹⁵; Nay et al. ²⁰⁰⁹; Nieuwenhuis et al. ²⁰²⁵). For our study, we use McCormack and McCance's Person‐centred Practice Framework (PCPF) (McCance and McCormack ²⁰²³) for several reasons. First, this framework is recognised as one of the most robust person‐centred care models (McCance et al. ²⁰²¹), having been researched and co‐developed with practitioners and service users across a variety of healthcare settings and populations over two decades. This framework has been used in at least 27 countries and translated into 12 languages (Norwegian, Swedish, Finnish, Danish, French, Dutch, German, Portuguese, Spanish, Malaysian, Mandarin, Slovenian). Second, the PCPF recognises the dynamic, complex and layered nature of person‐centred care at the different levels of the healthcare system, from the individual level through to the macro context. Third, and perhaps most importantly, this framework considers the wellbeing of care providers in addition to the needs of care recipients, families and caregivers. This is significant because provider wellbeing is essential to creating and sustaining healthful cultures and achieving healthful outcomes (McCance and McCormack ²⁰²³), which are at the core of the PCPF.

2. Background

While the principles of person‐centred care, specifically those of the PCPF, sound compelling as mechanisms to improve the quality of healthcare and foster the provision of value‐based care (Lewis et al. 2023), implementing them in practice has been shown to pose challenges (Byrne et al. 2020). Many of these lie in (macro) contextual and environmental factors such as productivity and cost effectiveness imperatives constraining the work of healthcare providers (Coulter and Oldham 2016; van der Cingel et al. ²⁰¹⁶; McCance et al. ²⁰¹³; Zadro and Maher ²⁰²²). Other challenges are grounded in professional, cultural and attitudinal factors including dominance of the biomedical model, healthcare professionals' assumptions and biases towards diverse populations, and organisational hierarchies and power relationships (Zadro and Maher 2022; Buckley et al. ²⁰¹⁴). Privileging person‐centredness would require embedding its principles in organisational systems and priorities, which would demand significant organisational change in some areas, as well as continuous investment in staff development and self‐reflection processes to ensure providers' values, attitudes and beliefs are aligned with and responsive to patient needs.

Enacting person‐centred care is particularly complex yet important in relation to minority populations who can be additionally and intersectionally marginalised by healthcare systems primarily designed to serve the general population (Pelleboer‐Gunnink et al. ²⁰¹⁷; Chauhan et al. ²⁰²⁰; Ayhan et al. ²⁰²⁰). While the implementation of the PCPF has been evaluated in some very challenging contexts such as acute care, residential aged care, palliative care and dementia care (McCance et al. ²⁰¹³; Buckley et al. ^{2014, 2018}; Haraldsdottir et al. ²⁰²⁰; Mayer ²⁰²⁰), its practical use has not been studied in relation to the provision of school‐based healthcare service delivery or the vaccination of people with IDD (Doherty et al. 2020; Jackman‐Galvin and Partridge ²⁰²²; Molnar et al. ²⁰²⁴; Maxey and Beckert ²⁰¹⁷). However, in a non‐vaccination‐related context, it has been found that person‐centred practice, including patients' and their families' active participation in decision‐making, is likely to result in better outcomes and fewer unmet needs of people with IDD, which in turn can contribute to better quality of life, health and wellbeing (Ratti et al. 2016; İsvan et al. ²⁰²³; NDIS Quality and Safeguards Commission ²⁰²⁵). Person‐centred practices that involve the co‐creation of care between patients and healthcare staff are also likely to increase job satisfaction and wellbeing among healthcare staff who tend to experience high levels of work stress and burnout related to the challenges of caring for people with IDD (van der Meer et al. ²⁰¹⁸). None of these benefits of person‐centred practice can however be achieved without appropriate financial and time resource allocation, specialised staff training in the areas of disability care and person‐centred practice (Mansell and Beadle‐Brown ²⁰⁰⁴), and clear procedures for implementing and evaluating person‐centred care goals and outcomes (Nieuwenhuis et al. 2025).

These findings highlight the need to explore practical strategies for implementing person‐centred care in school‐based vaccination programmes for adolescents with IDD.

3. Study Aim

This theoretical framework analysis is based on the findings of the Vax4Health phase 1 study (Carter, Klinner, et al. ²⁰²⁴; Klinner et al. ²⁰²⁵; Carter et al. ²⁰²⁴; Young et al. ²⁰²⁵; Zaina et al. ²⁰²⁵), which identified opportunities and challenges of improving the school vaccination programme for adolescents with IDD in special schools in the state of New South Wales (NSW). We focused on special schools (defined further in the Method section) since studies show that students in these settings have complex support needs in relation to vaccination (Tuckerman et al. 2024; Carter, Klinner, et al. ²⁰²⁴; Klinner et al. ²⁰²⁵; Carter et al. ²⁰²⁴; Young et al. ²⁰²⁵; Zaina et al. ²⁰²⁵; O'Neill ²⁰²⁰) and substantially lower vaccination rates than students in mainstream settings (O'Neill et al. ^2019a; Vujovich‐Dunn et al. ²⁰²¹; O'Neill et al. ²⁰²⁰; National Centre for Immunisation Research and Surveillance Australia ²⁰²³).

We theoretically examine the Vax4Health phase 1 study findings through the lens of the PCPF (McCance and McCormack ²⁰²³), using the research question ‘How can applying the principles of the PCPF improve the vaccination delivery for adolescents with IDD in special schools?’ We theorise that applying the principles of person‐centredness in this unique school‐based healthcare setting has the potential to improve vaccination equity and the health and wellbeing of adolescents with IDD (Petcu et al. 2017; Dew et al. ²⁰¹⁹), with positive flow‐on effects to the wellbeing of parents, teachers and immunisation nurses involved in or affected by this healthcare service. We also theorise that person‐centred vaccination of adolescents with IDD that centre around positive experiences for all persons involved (‘human flourishing’; Titchen and McCormack ²⁰¹⁰) may also increase vaccination rates in this population.

4. Method

4.1. Setting

More than 60 countries worldwide have vaccination programmes in schools (Bruni et al. 2016; Perman et al. ²⁰¹⁷). In Australia, school vaccination programmes have been, for many years, the primary method of delivering adolescent vaccines funded under Australia's National Immunisation Program including, in NSW, human papillomavirus (HPV), diphtheria‐tetanus‐pertussis (dTpa) and meningococcal ACWY vaccines (Ward et al. 2013). Each state and territory's health department operates these programmes in partnership with the education sector. In NSW, the programme is operationalised according to a state‐governed protocol. This protocol is executed by public health units in collaboration with high schools whereby mobile immunisation nursing teams visit the schools on pre‐arranged school days. Students whose parents have consented are then vaccinated at school by a team of nurses. Students who are unable to receive a vaccination on the day are usually offered one or two catch‐up opportunities at school, but parents need to find alternative, usually community‐based vaccination options if these opportunities are missed or not offered by schools.

The vaccination programme is operationalised in all schools, including Schools for Specific Purposes, or ‘special schools’ without formal policy provisions for reasonable adjustments to the vaccination process, although staff often make informal adaptations in practice. Special schools provide specialist and intensive levels of support for students with significant learning and support needs due to physical and/or intellectual disability, mental health issues or autism, learning difficulties and behaviour disorders (NSW Government ²⁰²⁴). At the time of the study, 181 special schools in NSW (Australian Bureau of Statistics ²⁰²³) were catering for approximately 6200 students (NSW Government ²⁰²³). Nationally, more than 43,000 children were attending 472 special schools (O'Neill et al. ^2019b). While this research focuses on students in NSW special schools due to their high support needs, it is worth noting that in Australia, 10% of school students, or around 380,000 children, have a disability (Australian Institute of Health and Welfare ²⁰²³). Of these students, 9 out of 10 attend mainstream school, underscoring the scale and importance of inclusive school vaccination programmes in every setting across the country.

4.2. Data Sources

The study draws on findings from phase 1 of the Vax4Health project (Carter et al. 2024), www.kirby.unsw.edu.au/vax4health, a qualitative study that investigated the barriers and facilitators to participation of adolescents with IDD in school vaccinations at special schools in NSW and ways to optimise these services. This study was completed in 2023 and comprised semi‐structured in‐depth interviews with 50 participants. It explored participants' experiences and perceptions of the vaccination programme in special schools, including what works well and what might help achieve higher vaccination rates and more positive vaccination experiences. Participants were recruited from five local health districts and four special schools (two in metropolitan areas and two in regional areas) in NSW. They included 16 service users (students with intellectual and autism‐related disabilities and parents), 10 service providers (nurses, programme coordinators and policy managers) and 24 service facilitators (school principals, teachers and learning and support officers). Participants were recruited indirectly through participating schools and public health units. The perspectives of students with disability were elicited through inclusive interviewing methods (Johnson and Walmsley 2003), using Easy Read materials, pictures, asking simple questions and having teachers present during interviews for support and to facilitate communication, as required. Data were thematically analysed using a 7‐step framework method (Gale et al. 2013) involving transcription, familiarisation and coding of the data, developing an analytic framework, followed by indexing, charting and interpreting data. A more detailed description of the study method including participant demographics, interview schedules and analytical processes are reported elsewhere (Carter, Klinner, et al. ²⁰²⁴).

4.3. Study Design

Using the results from the above‐described Vax4Health project, mapped against the PCPF, we theorise the degree of person‐centredness of the current NSW school vaccination programme. We do so by exploring the key factors that influence person‐centred delivery of school vaccinations to adolescents with IDD in special schools.

4.4. Theoretical Framework Analysis

This theoretical analysis was conducted in a four‐step process. Each step was drafted by the lead author of this article, followed by critical discussion and collaborative refinement by the research team which consisted of experts in the field of school vaccination, intellectual disability, person‐centred healthcare practice and advanced nursing. The four steps comprised the following activities: First, we identified the elements of the school vaccination programme that relate to the four domains of the PCPF (Table 1). Second, we connected the Vax4Health study's key findings, originally arranged into programme capacities and challenges by interested party (Appendix S1), to the domains of the PCPF. This resulted in a matrix of programme capacities and challenges by PCPF domain, illustrating the PCPF constructs operating and intersecting in action (Table 2). Third, we explored, domain by domain, to what extent the school vaccination programme aligns with the constructs of the PCPF, identifying key factors influencing person‐centred school vaccination care for adolescents with IDD, with a focus on special schools where support needs are highest (Figure 1). Fourth, we synthesised these key influencing factors into three themes, which describe the core vaccination programme characteristics influencing person‐centred practice for service providers, facilitators and users, respectively (Figure 2). We use these themes as a starting point to discuss how the community might shape school vaccination for students with disability towards a more person‐centred service delivery.

TABLE 1.

Person‐centred practice framework domains and school vaccination.

PCPF domains (from macro to micro level of practice)	Description	Related elements of the school vaccination programme
Macro context	The strategic and political factors that inform, guide and regulate person‐centred healthcare delivery	School Vaccination Protocol; Department of Education Restrictive Practices Framework Strategies the Departments of Health and Education use to collaborate in programme planning and operationalisation
Prerequisites	The attributes of healthcare providers needed to deliver the vaccinations in a person‐centred way	Immunisation nurses' professional competence; Nurses interpersonal skills, including ability to relate with adolescents with IDD; Nurses awareness of own and others' values and beliefs and how these may impact the care experience; Nurses commitment to achieve best possible health outcomes
Practice environment	The context in which the healthcare service is delivered, consisting of three sub‐domains: people, processes and structures	Physical environments conducive for calming anxious students whilst also enabling medically safe vaccination; Supportive organisational systems in schools and Public Health Units; Skilled staff, effective staff relationships and communication processes that facilitate shared decision‐making between nurses, school staff, parents and students
Person‐centred processes	The activities involved in delivering vaccinations to students in special schools	Health and Education staff working with students' and parents' beliefs and values, acting authentically, being sympathetically present, paying attention to families' psychosocial circumstances and needs and sharing decisions

Note: This framework is currently on hold due to a broader review of the Department of Education's approach to restrictive practices.

TABLE 2.

School vaccination programme capacities and challenges by each domain of McCormack and McCance's Person Centred Practice Framework.

PCPF domains	Capacities	Challenges
Macro context The strategic and political factors that inform, guide and regulate person‐centred school vaccination delivery	Parent‐centredness Online consent is efficient for Public Health Units and parents with Medicare* card and good IT access and IT literacy Nurse‐centredness Health policy makers provide leeway to and trust their vaccination provider staff to use ‘best practices’, professional experience and good team spirit to appropriately engage and vaccinate students with disability School‐centredness NSW Health works in partnership with schools to offer free vaccines to students *Medicare is Australia's medical insurance scheme funded by Australian taxpayers. It provides free or low cost basic healthcare	Parent‐centredness Online consent is unavailable to parents without Medicare card and IT access or IT literacy The NSW Health vaccination information pack and clinical protocol are not tailored to families with special needs The policy change to HPV single dose has reduced the number of catch‐up vaccination opportunities at school Specialist vaccination services for students who cannot be vaccinated in the school programme are difficult to access for parents (only by GP referral) and referral pathways are not well known by parents and schools Alternative community vaccination options (GP, vaccination clinics, pharmacies) are less suitable for families with disability than school vaccinations due to long waiting times, noisy, crowded clinics and lack of specialist provider skills which can elevate student anxiety Student‐centredness Clustering school vaccination clinics causes uncertainty in schools about nurses' arrival time and can increase student anxiety There is a lack of public resources available for individualised student preparation School‐centredness There is a lack of regulation, transparency and consistency across schools, regarding schools' responsibilities in facilitating the vaccination programme (e.g., regarding distribution of vaccination info pack, assistance with and follow up of consent forms, school coordinator role and responsibilities, monitoring of students and informing parents after vaccination) The Restrictive Practices Policy is unclear and enacted inconsistently between individual school staff and across schools Schools are not incentivised or reimbursed for facilitating the vaccination programme There is no formalised reporting back to schools if students were vaccinated elsewhere
Prerequisites The attributes of health providers (professional competence, interpersonal skills, commitment to the job, clarity of values and beliefs)	Parent‐centredness Nurses are highly motivated to educate parents about vaccines School and student‐centredness Nurses collaborate well with teachers on vaccination day, they listen to teachers' advice how to support individual students and they may involve teachers in the decision‐making about ending vaccination attempts Student‐centredness Nurses bring empathy, flexibility and professional experience to the role which assists them in vaccinating difficult‐to‐vaccinate students, and improving the vaccination experience for all	Nurse and student‐centredness Nurses lack disability specific training and skills Nurses may hold assumptions about students' cognitive (in)capacity to understand and be involved. Especially non‐verbal students and those with severe intellectual disability tend to be deemed difficult to manage, and therefore may be ‘surprised’ with vaccination Nurses' ability to relate well with students with disability varies between individual professionals
Practice environment The context in which the vaccination care is delivered including supportive organisational systems, power sharing, person‐centred staff relationships and conducive physical environment	School‐centredness Schools serve as a bridge between service provider and service receivers by hosting and facilitating the vaccination programme Student‐centredness Vaccination rooms are set up (by schools) in ways that provide maximum familiarity and comfort for students Parent‐centredness A parent information pack is provided to parents via the schools, including contact details of the public health units if parents wish to discuss vaccine‐related questions School and student‐centredness Some nursing teams consistently visit the same special schools and this assists building relationships with schools and students Nurse‐centredness Some teachers share individualised information about students to nurses on vaccination day, allowing for tailoring of care	School‐centredness Schools experience resource constraints to facilitate vaccination clinics (e.g., fitting clinic days into the curriculum; distributing and collecting consent forms; offering and following up parental consent; preparing students; informing parents of vaccination outcomes) School coordinators receive a guide on how to prepare for the vaccination clinic at their schools, but appear to lack formal training and financial incentives to fulfil their role Parent‐nurse centredness Nurses do not have a direct line of communication to parents, reducing opportunities to actively reach out to parents who may hesitate or object to vaccination Student‐nurse centredness Nursing team consistency is not guaranteed and this may increase student anxiety Nurses have little to no information of students' individual needs prior to coming to school, which can make it difficult to ‘individualise’ their service to students' needs In some jurisdictions, nurses may work on pre‐set time schedules with multiple schools in a day, which can make it difficult for them to take time for students, build rapport and trust with students
Person‐centred processes The activities involved in delivering the healthcare service: working with the person's beliefs and values; sharing decision‐making; engaging authentically; paying attention to person's psychosocial circumstances; being sympathetically present		Parent‐student centredness Parental vaccination misbeliefs (e.g., vaccination causes autism; young people with disability are not sexually active and therefore don't need HPV vaccination) can, if unaddressed, lead to parents rejecting vaccination Low parental health literacy and lack of trust in healthcare providers can, if unaddressed, lead parents to reject vaccination or not submit a consent form which equals forgoing vaccination Heightened parental sensitivities, worries and health concerns for their children with disability can, if unaddressed, lead parents to reject vaccination Follow up of parents' (reasons for) not consenting is not formalised. This information can therefore not be used as an opportunity to discuss parents' vaccination beliefs, answer questions, or address concerns Parents involvement in getting students vaccinated at school is limited in several ways: Student preparation is not coordinated between parents, school and nurses, nor systematically integrated across schools state‐wide The options of parents coming to school to support their child for vaccination appears to be an underutilised strategy The absence of parents during vaccination hinders shared decision‐making about how to engage and support a student during vaccination and when to end a vaccination attempt if a child shows distress
	Student‐centredness (pre‐vaccination) Personalised student preparation using tools such as social stories about what will happen, educational videos and simple slogans appear to help reduce vaccination anxiety in some students with IDD	Student‐centredness (pre‐vaccination) Students with high levels of needle anxiety or severe IDD tend not to be prepared for vaccination, either to avoid pre‐vaccination anxiety build up or because of assumptions of their capacity Personalised student preparation using tools such as social stories, videos, or simple slogans are underutilised Students' vaccination knowledge and interest to be involved in their health decisions is underutilised
	Student‐centredness (during vaccination) Parents' presence during the procedure can make school vaccinations more comfortable for some students with IDD. Some behavioural approaches used by nurses reduce student anxiety, enhance students' willingness to collaborate with the vaccination team and have an overall more satisfying and positive vaccination experience: Giving students some control over how the event unfolds Addressing students' situational fears, needs and wishes Gaining students' trust before vaccinating (or intending to vaccinate), e.g., by showing an interest in the student as a person De‐emphasising the goal to vaccinate, prioritising safety, wellbeing and respect for the person Positive, encouraging language Respecting students' physical agency over their body Providing a supportive, comfort position for students who want it Adapting vaccine administration approaches to students' needs and preferences Having a trusted support person or companion animal present Incentivising, rewarding and praising students Having the option to defer the vaccination to another date Immediately returning students to their familiar routine and calming environment	Student‐centredness (during vaccination) Behavioural approaches used by nurses found to increase student anxiety: Surprising students with the event/needle can cause anger, resentment, or trauma and erode trust in healthcare providers Using coercive or negative language with the student can cause ‘performance anxiety’ Not addressing students' individual needs (e.g., need for physical comfort, desire to be treated with curiosity and respect and to know the nurse before getting vaccinated) can stifle students' willingness to collaborate Not adequately managing past medical, social or needle trauma can exacerbate anxiety/trauma Seeing the needle and/or hearing trigger words (e.g., ‘needle’, ‘vaccination’) can exacerbate anxiety Holding students against their will can cause anxiety, anger and trauma Seeing/hearing peers' anxiety outbreaks (contact between vaccinated and not‐yet‐vaccinated students) can elevate student anxiety Dragging the process out (‘desperately trying to get the needle in’) can increase student anxiety and make it hard for them to cope; in some cases, this can result in safety issues and/or trauma
	School‐centredness Schools provide many activities essential to the success of delivering the vaccination programme, with varying levels depending on the school. These include for example: making time in the curriculum for vaccination clinics; distributing vaccination info packs, assisting parents with filling out consent forms and following up unreturned forms; setting up vaccination room to maximise comfort for students; preparing students for vaccination; providing nurses with information about individual students' needs; emotionally supporting students during and after vaccination; monitoring students after vaccination; support with communicating vaccination outcomes to parents; and providing a venue for catch‐up clinics	School‐centredness Schools receive little guidance and support to facilitate the vaccination programme Schools' levels of support of the vaccination programme are inconsistent between schools and individual school staff
Outcomes The results of effective (or not‐so‐effective) person‐centred vaccination care	Parent and student‐centredness Parents value the convenience of school vaccinations and the child‐friendly, supportive treatment that their children receive on vaccination day by familiar, trusted teachers/support personnel	Parent‐centredness Leaving parents' vaccine‐ and disability‐related concerns and questions unaddressed, can lead them to decide against getting their child vaccinated Lack of reporting back to parents on how school vaccination went leaves parents concerned about how their child was coping with getting vaccinated in their absence
	Student‐centredness Students tend to feel safer receiving vaccines at school than elsewhere due to the familiar school environment and presence of trusted teachers/support personnel	Student‐centredness Negative or traumatic school vaccination experiences can cause or perpetuate needle anxiety Negative or traumatic school vaccination experiences can erode students' trust in teachers and schools as safe places, which can lead to school/teacher fear and avoidance Not providing any form of physical reassurance to students can forgo an important opportunity to calm students down who respond well to physical touch such as a comforting hold Difficult‐to‐vaccinate students may not be able to be vaccinated at school, and be either vaccinated in less‐favourably community‐vaccination settings or needing specialist vaccination services
		School‐centredness Schools don't know the vaccination status of students who were vaccinated elsewhere Some schools believe that educational institutions are the ‘wrong’ place to perform vaccinations Nurse‐centredness Nurses experience distress when they don't know how to engage students with disability for vaccination, when they see students' in distress and when they cannot vaccinate students safely Some nurses have expressed doubts around the programme's effectiveness in special schools

FIGURE 1.

Key factors influencing person‐centred vaccination for students with intellectual and developmental disability. Adapted from McCance and McCormack (2023).

FIGURE 2.

Influences of person‐centred delivery of school vaccinations to students with intellectual and developmental disability (IDD) in special schools in NSW.

5. Results

Person‐centred healthcare practice, according to the PCPF, has been defined as a humanistic care approach characterised by healthful relationships between service providers, service users and other persons involved in the care process (McCance and McCormack ²⁰²³). In our case, these ‘other persons’ are high school staff as facilitators of the vaccination programme. The practice is underpinned by values of dignity and respect for all, the right to speak up and be heard, being present, mutual understanding, collaboration, shared decision making and power sharing. Implementing this practice requires a dynamic work culture that encourages continuous practice development (Haraldsdottir et al. 2020; McCormack and McCance ²⁰¹⁶). The PCPF (Figure 1, centre diagram) comprises four interdependent domains (macro context, prerequisites, practice environment and processes) that need to conceptually align to generate the aim of the fifth domain, or central component of the framework: a healthful culture in which healthful outcomes and human flourishing for all persons involved can develop. In Table 1, we outline which elements of the NSW school vaccination programme conceptually relate to the respective PCPF domains.

Knowing which vaccination programme elements relate to which PCPF domain assisted us to thematically connect the vaccination programme capacities and challenges identified in the Vax4Health study (Carter et al. 2024) (Appendix S1) with the PCPF domains and their embedded concepts. Table 2 provides a detailed description of school vaccination programme capacities and challenges by PCPF domain.

Figure 1 visualises how these programme capacities and challenges, or ‘influencing factors’, relate to the domains and concepts of the PCPF, highlighting areas of improvement of person‐centred vaccination care for students with disability.

From these key influencing factors, we extrapolated three themes, depicted in Figure 2, which are seen to influence person‐centred delivery of school vaccinations to students with IDD in special schools.

These themes can be viewed as indicative areas for development of person‐centred cultures in vaccinating students with IDD, as outlined following:

5.1. Theme 1: PARENT‐AND STUDENT CENTREDNESS: Parents and Students With IDD Expressed Strong Support for the Programme but There Is Potential to Enhance Their Participation in Vaccination Decision‐Making Processes

5.1.1. Parent Centredness

The programme received strong support from parents who valued the convenience of having their child vaccinated at school in a child‐friendly, supportive and individualised way (Zaina et al. 2025). This alleviated parents from the responsibility of organising private vaccination appointments and from having to witness their child going through a pain and/or stress‐inducing medical procedure, described as time‐consuming and stressful for parents (Zaina et al. 2025). However, not being involved in preparing and attending their child's vaccination limited parents' inclusion in a collaborative approach. Parents' absence from the vaccination event also meant they had limited insight into how their child coped with the procedure.

Parents were also found to have limited opportunities to give informed consent to their child being vaccinated at school. They reported disability‐related sensitivities and protectiveness regarding their child's health and wellbeing. Their hesitancies related to (mis)beliefs about vaccines, fears of adverse health effects, previous negative vaccination encounters and concerns around how their child may react or be treated during the procedure (Carter, Klinner, et al. ²⁰²⁴). Moreover, vaccination information and consent forms were difficult to access and to understand for some parents. Vaccination information packs (at the time of writing) for parents did not contain disability‐specific information and were not tailored to populations with low literacy. This could lead parents with disability‐related questions and concerns, especially if they have an IDD themselves or are from a low socio‐economic background, to decline or miss school vaccination offers. Parents who are struggling to make an affirmative decision to get their child vaccinated at school due to disability‐related hesitancies or misbeliefs are currently not followed up by the healthcare system (McIndoe et al. ²⁰²⁴) as there are no routine provisions that would enable the education sector to share student data with NSW Health for the purpose of offering vaccinations at school. Disclosure of personal information is generally restricted under the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002. Without access to student and parent contact information, public health units rely on schools to send the online consent link to parents and distribute and collect hard copy consent forms. This can result in delays, low response rates and missed opportunities for vaccination. More accessible and tailored information and education of families with IDD as well as outreach options for health department staff to parents could improve this aspect of person‐centred vaccination (Carter, Klinner, et al. ²⁰²⁴; Choi ²⁰²⁵). This directly speaks to the person‐centred care principle of working with parents' beliefs and values located in the Processes domain of the PCPF with foundations in the Practice Environment (adjusting organisational systems to enable nurse outreach) and Macro Context domain (political will to support families with IDD in strategic frameworks and policies) (McCance and McCormack ²⁰¹⁷).

To address parents' desire to be better informed about and feel included in the vaccination event itself, several options may be worthwhile investigating: a low‐cost option might be for schools to routinely invite parents into school on vaccination day. This would enable parents to provide emotional support to their child and co‐decide with the healthcare‐teacher team when vaccination must be called off if the situation becomes too stressful for the student or unsafe for anyone involved. The opportunity for parents to be present at school vaccinations would also enable parents to learn on the spot about alternative or specialist vaccination pathways from the nurse team in case vaccination was unsuccessful. For parents who cannot or do not want to come to school on vaccination day to personally support their child, another option to improve parent‐centredness might be to facilitate a pre‐vaccination collaborative discussion between parents, nurses and the child's teacher who will be present at vaccination day. This discussion could be held online, via teleconference or via a written support plan and focus on agreeing on strategies how to best support the child. This option could be preferable to schools for whom inviting parents on vaccination day is not feasible, and in cases where students themselves prefer not to have their parents around.

Such options could improve person‐centred care specifically through sharing power and decisions with parents (Coulter and Oldham 2016), concepts that are embedded in the Processes domain of the PCPF, but also link in with the availability of shared decision‐making systems (Practice Environment domain) (McCance and McCormack ²⁰¹⁷).

5.1.2. Student Centredness

While students felt safer receiving vaccines at school than elsewhere due to the familiarity of the school environment and the presence of a trusted teacher or disability support officer (Zaina et al. 2025), they frequently also reported experiencing severe needle anxiety, not adequately managed within current protocols (Klinner et al. 2025). This could make vaccination events extremely distressing for students, triggering behaviours that others find challenging and resulting in new, or exacerbating existing, needle trauma. Students with IDD who participated in the Vax4Health study also identified a largely untapped interest in learning about their health and a desire to be included in vaccination decisions. For some students, this meant a desire to be prepared for vaccination (Young et al. 2025), for others to be more actively engaged in the vaccination event. Yet, in the current system, student preparation and student engagement during vaccination are enacted in an ad hoc way and are highly dependent on individual parents', nurses' and teachers' initiatives, motivations and beliefs (Young et al. 2025). This counters international healthcare guidelines and health ethicists' calls for the inclusion of adolescents with IDD in shared decision making before proceeding with clinical interventions (Klinner et al. 2025; Adams et al. ²⁰¹⁷).

Individual initiatives that were experienced in the Vax4Health study as effective in preparing students with IDD for vaccination and mitigating anxiety included, for example, individually tailored social stories and short, simple slogans like ‘better cry than die’. Such initiatives could help students with IDD understand how vaccines, while they may hurt in the moment, protect against the long‐term harmful effects of preventable diseases (Carter, Klinner, et al. ²⁰²⁴; Young et al. ²⁰²⁵).

Not consistently and collaboratively recognising and acting on students’ preferences and needs in relation to vaccination can have detrimental effects on students’ sense of psychological safety and, in the worst case, contribute to life‐long needle trauma (Orenius et al. 2018; Klinner et al. ²⁰²⁵; Bray et al. ²⁰¹⁶; Jenkins ²⁰¹⁴). It may also inhibit the development of their sense of agency and self‐worth (Dew et al. 2019; Brown and Brown ²⁰⁰⁹). These negative outcomes are diametrically opposing the person‐centred care principle of ‘Enabling human flourishing’, a person‐centred goal located in the Outcome domain. They are directly related to the concepts of working with students’ beliefs and values, sharing decision making, engaging authentically and being sympathetically present (Processes domain). They are also related to healthcare providers’ degrees of clarity of beliefs and values, their professional competence and interpersonal skills (Prerequisites domain) and to the Departments of Health and Education’s strategic commitment to person‐centred care values (Macro domain) (NSW Department of Education ²⁰²⁴; NSW Health ²⁰²⁴; NSW Health (Clinical Excellence Commission) ²⁰²⁴).

Key stages in the journey to vaccination that could be approached in a more collaborative, shared‐decision making—hence ‘person‐with‐IDD centred’ way—include supporting parents in the decision‐making process of consenting to their child being vaccinated at school, preparing students for vaccination, deciding how individual students can be emotionally supported during vaccination and when vaccination needs to be called off for psychological and/or physical safety. This kind of collaboration would require all parties to make additional time in their already busy work schedules. In the current system, this appears prohibitive for at least school and health staff (Young et al. 2025), an issue that might need to be addressed on the Macro and Practice Environment levels.

5.2. Theme 2: NURSES PERSON‐CENTRED APPROACH: Nurses Bring High Levels of Motivation, Clinical Experience, Empathy and Creativity to Vaccinating Students With IDD but Opportunities Remain to Enhance Disability‐Specific Training and Knowledge of Individual Students' Needs

Person‐centredness in school vaccination programmes also applies to care providers. These comprise immunisation nurses, public health units who employ the nurses and the Department of Health who oversees and governs the vaccination programme. Similar to other studies investigating the implementation of person‐centred care, our study highlighted nurses’ high motivation to vaccinate adolescents with IDD (Zaina et al. 2025) as well as their ‘professional artistry’ (van der Cingel et al. ²⁰¹⁶, 10) which was characterised by nurses’ patience, empathy and creativity in engaging and distracting distressed students. Yet, in the Vax4Health study, nurses (particularly those with less experience) reported high levels of distress, paired with limited confidence, in vaccinating students with IDD. Lack of confidence related to insufficient or complete absence of knowledge about individual students’ needs as well as a lack of disability‐related skills foundation for engaging and supporting adolescents with IDD (Klinner et al. 2025). This indicates that, when working with students with IDD to deliver vaccinations in ways that best meet their needs, nurses needed more than clinical skills and ‘professional artistry’. They needed to have advanced self‐knowledge as well as observation and communication skills that go beyond caring for the general population (McCormack et al. ²⁰²¹) and specifically centre around engaging people with IDD, including those with limited or no verbal communication. These skills involve not only recognising students with IDDs’ selfhood but also responding to and supporting their expressions of self, whether that be verbal or non‐verbal. This requires nurses to have a professional understanding of IDD so they can be truly ‘sympathetically present’, develop a genuine therapeutic relationship, explore students with IDDs’ wishes and feelings and respond to manifestations of anxiety. These staff qualities (Prerequisites domain) could be embedded in a supported decision‐making approach (Browning et al. 2017) in which staff work with students’ beliefs and values (Processes domain) and share power (Practice Environment domain) to help students gain knowledge about the importance and process of vaccination, and experience a sense of active participation, control and empowerment in the vaccination process (Klinner et al. 2025; Notara ²⁰²¹; Watson and Frawley ²⁰²³). Possible ways of addressing nurses’ IDD‐related skills gap (Prerequisites domain) could be through specialist training programmes similar to the Learning Disability Nurse model ¹ developed by the UK Foundation of Nursing Studies (Cope and Shaw 2019) or, more locally, via Australian initiatives such as PANDDA (The Professional Association of Nurses in Developmental Disability Australia Inc ²⁰²⁵), the Council of Intellectual Disability (Council for Intellectual Disability ²⁰²⁵), the National Centre of Excellence in Intellectual Disability Health (National Centre of Excellence in Intellectual Disability Health ²⁰²⁵) and NSWISS (NCIRS ²⁰²⁵). Person‐centred care models could also involve the employment of IDD‐specialised nurse leaders or IDD liaison nurses whose role could be to train and support school immunisation teams who visit special schools (Cardiff et al. 2018; Brown et al. ²⁰¹⁶). Such programmes and care models will need to be complemented by an organisational person‐centred care orientation to ensure nurses are not only disability experts but also person‐centred care experts who are embedded in a person‐centred organisational culture and system that supports them (İsvan et al. 2023). For example, immunisation nurses may benefit from more generous time allocations when visiting special schools to enable them to slow down the pace of their vaccination schedule, be sympathetically present and engage authentically with students with IDD before offering them vaccination. More generous vaccination time allowances would also provide vaccination providers room for decision‐making to balance their professional judgement with local information and student/family preferences on a case‐by‐case basis. This may be particularly important in situations where a student is difficult to vaccinate due to high levels of anxiety (O'Neill et al. ^2019a). While staff time allowances are an important characteristic in the Practice Environment domain of the PCPF, they are governed by policy frameworks, such as the state vaccination protocols that sit within the Marco domain.

Indeed, research shows that implementing more person‐centred healthcare approaches that enable patient empowerment and shared‐decision making are not only enhancing the quality of care for service receivers but also improve the wellbeing and job satisfaction of the health professionals working with people with IDD (van der Meer et al. ²⁰¹⁸).

5.3. Theme 3: SCHOOLS' COMMITMENT: Special Schools Are Committed to Supporting Families With IDD and Facilitating the Programme but Limited Resourcing and Unclear Responsibilities Can Present Challenges That Need Addressing

Person‐centredness also relates to schools as facilitators of the vaccination programme, forming a crucial bridge between care providers and care receivers. While special schools were highly committed and invested in preparing, hosting and facilitating the programme and supporting parents, students and nurses in this process, they were unclear about the extent of their responsibilities in operationalising the vaccination programme and encountered challenges related to inadequate resourcing. They also experienced difficulties navigating ethical concerns related to holding students during vaccination for physical support due to unclear departmental restrictive practices guidelines.

Research shows that, in order to create a lived culture of person‐centred healthcare, person‐centred principles, thinking and acting need to be made explicit as organisational commitments (Yalden et al. 2013) and supported by strategic leadership (McCormack et al. ²⁰²¹), policy change and resource allocation (Mansell and Beadle‐Brown ²⁰⁰⁴). Whether this is the case in school vaccination programmes for students with disability is unclear. Our study showed that special schools largely fulfil their vaccination‐related commitments at their discretion and to varying degrees of detail. According to participants' narratives, expectations on schools were neither transparent nor formalised or consistently communicated across Health Districts, and schools were not financially or otherwise resourced or rewarded for their commitment in action (Zaina et al. 2025). These issues sit in the Practice environment (supportive organisational systems) with roots in the Macro domain of the PCPF (supportive strategic frameworks, health and social care policy).

The Vax4Health study findings also point to another Macro contextual factor that might hinder ‘person‐centred vaccination care for students with IDD: the Department of Education's Restrictive Practices Policy (RPP), which, in its current form, has caused confusion and inconsistent implementation among school staff participating in the Vax4Health study (Klinner et al. 2025). According to the study, teachers and support staff accompanying students during vaccination were torn between, on one hand, wanting to give students physical comfort and support and assist with safe needle injection (e.g., by holding a student's arm or hand), but being prohibited from using unacceptable holding practices, by act of the RPP on the other. This illustrates how a Macro level issue, i.e., the RPP, can lead to challenges at the clinical interface hindering the operationalisation of a person‐centred vaccination Process in special schools. Lack of strategic (Macro‐level) support for person‐centred practice is not new. A study performing a secondary analysis of five empirical studies of how the PCPF is expressed in practice identified (Macro) contextual factors, especially working cultures marked by work stress and lack of time, as well as productivity and cost effectiveness issues, as the main barriers to the enactment of person‐centred care (van der Cingel et al. ²⁰¹⁶).

The issues special schools experienced in their role as intermediaries between vaccination service providers and receivers also point to a need to adapt the PCPF regarding how ‘staff/workforce’, ‘workplace/organisational systems’ and ‘strategic leadership’ are interpreted to fit into the context of the school vaccination programmes. In contrast to most other health services, this programme is a triadic construct of care providers, facilitators and users. Although described as a health programme, vaccinations occur in an education setting and the programme intensively involves schools' commitment, input and engagement. Schools act as facilitators, supporters and mediators of the programme by supporting the consent process, relaying knowledge and information between care providers (public health units and nursing teams) and care recipients (families with IDD), providing and preparing the vaccination venue and emotionally supporting students and parents throughout the vaccination journey. This raises the question of the extent to which one can or should extend the requirements that the PCPF places on service providers to schools, and, if so, which criteria should be used to measure the fulfilment of the requirements that person‐centred healthcare might place on schools as educational institutions. This also suggests a need to more clearly formalise and support schools' role in programme delivery. While schools receive guidance on their responsibilities, study participants suggested that schools differ in their interpretations of their responsibilities and in their levels of commitment to the vaccination programme. A revision of strategic agreements between the Health and Education Departments might be indicated to make schools' responsibilities in the vaccination programme more transparent, appealing to and supportive of special schools. Further supports might entail training school staff in person‐centred care principles or funding the role of a school vaccination programme coordinator. These issues would need to be addressed on a Macro level with flow‐on effects on the Prerequisites (enhancing school commitment to the programme), the Practice Environment (supportive organisational systems) and the Outcome domains (sustained organisational commitment) of the PCPF.

We have summarised some suggestions to make school vaccinations for adolescents with IDD more person‐centred for all parties involved in Table 3.

TABLE 3.

Suggestions to make school vaccinations for adolescents with IDD more person‐centred for all parties involved.

PCPF domains	Suggestions
Macro context	Parent‐centredness Tailor vaccination information packs to families with IDD. Provide accessible referral pathways to specialist services to parents of adolescents who require additional assistance Student‐centredness Offer reasonable adjustments in vaccination protocols, practices and communication to accommodate students' individual needs Resource allocation to schools, nurses and families for collaborative, individualised student preparation School‐centredness Increase clarity regarding schools' responsibilities in facilitating the vaccination programme including clear communication of policies related to child safety and wellbeing such as the use of restrictive practices Provide appropriate support and resource allocation for schools to fulfil their responsibilities effectively Promote exchange of information between schools and health to better meet students' needs
Prerequisites	Nurse and student‐centredness Provide nurses with training in person‐centred care and working with adolescents with disability
Practice environment	School‐centredness Pro/re‐vision of guides for schools on how to fulfil their role as vaccination programme facilitators Offer training opportunities and support for school vaccination programme coordinators Nurse centredness Promote communication and collaboration between nurses, schools and families prior to vaccination clinic so nurses can plan strategies to support students' needs Offer flexible and longer clinic time allocations for nurses vaccinating students with IDD
Person‐centred processes	Parent‐centredness Provide opportunities for nurses to connect directly with parents to support vaccination decision‐making Formalise follow‐up of parents who do not submit a vaccination consent form Support collaborative student preparation between families, school and nurses, including medical history, beliefs and experiences Allow/invite parents to come to school on vaccination day to support their child Student‐centredness Utilise customizable educational tools to prepare students for their vaccination, based on individual student preferences and needs Involved students in the vaccination process through supported decision‐making such as choosing a familiar comfort item or the arm to have the vaccine in Support nurses to build trust and rapport with students before the procedure and show empathy and patience Respect the child's feelings and their right to safety and wellbeing, including not using force, not surprising them with the needle and not prolonging the procedure unnecessarily School‐centredness Provide consistent guidance and support to all schools to facilitate the programme
Outcomes	Parent‐centredness Report back to parents how school vaccination went to support learning and success for future procedures Student‐centredness Prioritise student wellbeing over vaccination outcome Nurse‐centredness Provide debriefing and learning opportunities for nurses School‐centredness Report back to schools the vaccination status of students who were vaccinated elsewhere

6. Conclusion

This study theoretically applies the principles of McCormack and McCance's Person‐Centred Practice Framework to a school vaccination programme, drawing on the findings from the Vax4Health project on the experiences and perspectives of all interested parties of vaccinating adolescents with IDD at special schools in NSW. By connecting the Vax4Health study findings with the PCPF domains and matching them with the principles characterising these domains, we were able to identify areas for improving person‐centred vaccination care for all interested parties whilst also drawing on the capacities of the current school vaccination programme. To our knowledge, this is the first time such an analysis has been undertaken using person‐centred care principles in relation to vaccination and young people with IDD in an educational setting. In theorising how the vaccination programme characteristics and opportunities sit with the principles and domains of the PCPF, we also identified a potential need to adapt the PCPF to a triadic health service construct such as the NSW school vaccination programme that is delivered to families with IDD by the Health Department and facilitated by the Education Department and their schools. Future research could be directed towards practically applying the PCPF, or an adaptation thereof, to vaccinating adolescents with IDD at special schools, with consideration also given to students in mainstream settings. It is important to include in such investigations the group of adolescents with limited or no communicative abilities who require specific and intensive support so that effective and meaningful person‐centred vaccination care is accessible to them as well as to adolescents who can verbally communicate their needs (Nieuwenhuis et al. 2025). This could entail a co‐design process in which interested parties, including families with members with profound intellectual disability, are engaged in designing and prototyping ideas to improve the vaccination programme towards becoming a more person‐centred healthcare service. Such a co‐design process is currently being undertaken by our research team.

This paper offers novel insights that contribute to the understanding of person‐centred care in school vaccination programmes for adolescents with IDD and may have implications for school‐based healthcare delivery models in similar contexts internationally. While the WHO (2025b) and UNICEF (2017, 2023) support and promote school‐based vaccination strategies globally, and many countries around the world have school vaccination programmes (WHO ^2025a), none have written in‐depth about disability inclusion. Australia's school vaccination programmes in specialist education settings appear to be spearheading the development of person‐centred vaccination practices for adolescents with IDD by addressing service challenges and reducing access barriers (Musuka et al. 2025). More work needs to be done nationally and globally to strengthen school vaccination programmes for adolescents with IDD. Key areas for improvement include parental and student empowerment and inclusion, specialised provider training, development of inclusive policies that support diverse needs and enhanced collaboration between Health and Education ministries to ensure the provision of person‐centred care to all students (NDIS Quality and Safeguards Commission ²⁰²⁵).

Author Contributions

This study was conceptualised by C.K., A.Y., A.C. and B.M. The manuscript was developed by C.K. with significant input from B.M., C.E.N., A.Y. and A.C. It was critically revised by B.M., A.Y., C.E.N., T.S., D.B. and A.C. All authors provided final approval of the version to be published.

Funding

This study was funded by the New South Wales Health Prevention Research Support Program 2022–2026, the HPV Partnership Project (NHMRC 1132344), the UNSW Health Systems Research Theme 2024 Collaborative Grant and an Emerging Research Leader Award from the Centre for Research Excellence in Cervical Cancer Control (NHMRC 2015739). A.C. is supported by an Australian NHMRC Emerging Leadership Investigator Grant (2034148).

Disclosure

Patient or Public Contribution: The Vax4Health study was an inclusive and collaborative research project that actively involved people with intellectual disability, health professionals and school staff as research partners through a Community Advisory Board and lived experience research assistants. Only health professionals were involved in this paper's theoretical analysis.

Ethics Statement

Ethical approval for the Vax4Health study was received from the University of New South Wales Human Research Ethics Committee (Project no: HC210587).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: School vaccination programme capacities and challenges by interested parties.

Data Availability Statement

The data supporting the findings of this theoretical framework analysis are available within the article.