An advantage of using home based telephone interviews was that we found that we could recruit school nurses reasonably easily and that they could speak frankly about their views. However it is possible that the interviews were shorter than would have been the case if they had been face to-face interviews. Another limitation of this study is that the school nurses who participated may not be typical and may represent the more engaged members of their profession; nevertheless much of their experience finds resonance with findings from other studies. The school nurses who took part were generally well informed and willing to recommend HPV vaccination to parents and adolescents. However, findings from a online questionnaire which surveyed health professionals found that there was widespread support for the vaccination programme . Similar to findings of Lansley and Bedford (2003) who examined immunisation co-ordinators' views of the Meningitis C campaign when it was introduced in 1999, much of the credit for the high uptake of vaccines should go to the health professionals implementing the programme . School nurses considered themselves well placed to implement the school based programme and viewed the programme as a means of making a positive contribution to girls' health beyond the school years. Whilst they felt positive about the programme, they also believed that the programme had been unnecessarily rushed and had vastly increased their workload leading them to cut back on their core activities. Of particular concern was that they could no longer dedicate time to offer support to vulnerable pupils which they assessed as having a detrimental effect on the nurses' everyday practice and relationship-building with vulnerable pupils. These findings suggest a shift in responsibilities for health and raise questions over which pupils might be unintentionally left behind as a consequence of the vaccination policies and practices.
In relation to HPV policy, school nurses generally understood the rationale for targeting girls aged 12 to 13 years and, contrary to other findings , viewed younger adolescents as good candidates for these vaccines and easier to attain consent. However, school nurses raised concerns that by targeting the HPV programme solely at girls, boys were being excluded from taking responsibility for their role in spreading the virus. Such concerns draw parallels with Polzer and Knabe's assertions that the marketing of HPV vaccines directly at women may reinforce assumptions about the female body as the primary vector of sexually transmitted infections (STIs) . Whilst school nurses did not suggest that the vaccine should also be given to boys at present because of its high cost and need to ration health services, the marketing of the vaccine as a girls' vaccine could have implications for the future programme should it be rolled out to include boys if they do not regard the vaccine as relevant for their health. In this respect 'gendering' vaccines can be problematic. Previous research examining parents' views on vaccine preventable diseases found that rubella and mumps vaccines were perceived to be strongly gendered, rubella being commonly seen as an issue for girls and mumps for boys leading some parents to doubt the need for boys to be vaccinated against rubella, and girls against mumps .
As suggested by Szarewski  the school nurses found the lack of transparency of the Department of Health's decision to opt for Cervarix
frustrating. However, similar to Kane's suggestion , school nurses also supported the decision to opt for Cervarix
and felt it could more easily be promoted to parents as a cervical cancer vaccine rather than a STI vaccine, enabling them to attain higher uptake. However, some school nurses considered there was a need to promote greater awareness about HPV vaccination to avoid misconceptions that barrier methods and cervical screening are no longer needed. This echoes other research .
In relation to HPV vaccine decision-making school nurses identified three main reasons for parental refusal: allergies to latex, a belief that their daughter was not sexually active and therefore not at risk from a HPV infection, and concerns about unknown long-term side-effects of the vaccine on their daughters' fertility or that the vaccine could transmit the HPV infection. School nurses also identified needle phobia as a key reason for refusal among the older girls. In contrast to Monk and colleagues' finding that some parents may not give consent to vaccinate if they think their daughters will be given information that might encourage sexual risk taking , school nurses in this study did not recall any parents refusing HPV vaccination on the grounds that it might encourage their daughters to adopt more risky sexual behaviours.
School nurses generally considered that most parents were actively engaged in the process of making a decision and supported the vaccination programme, a finding consistent with research piloting the acceptability of the vaccine among parents in Manchester . School nurses also believed that there were also many parents who were 'passive acceptors' who consented for their daughter to have the vaccine without much thought. Another group of parents that school nurses identified and raised concerns about were the large number of parents who did not consent for their daughters to be immunised due to what was described as 'parental apathy'; we have termed such parents 'passive rejectors'. These parents were identified by school nurses as tending to come from deprived communities for whom health may not be the highest priority. School nurses believed that they could have most influence in increasing HPV uptake among these parents. As such any attempts to improve the uptake of vaccination may be worth targeting at this particular group of parents. Such interventions could include mobile immunisation services to vaccinate and gain parental consent. This research indicates that further research with these hard-to-reach groups into identifying what acceptable measures could be implemented to help overcome existing barriers to immunisation may prove fruitful. One group of parents that school nurses considered that they would be unlikely to influence were those who had rejected HPV immunisation. These 'active rejector' parents were viewed as hostile and disruptive during information sessions. Stretch and colleagues have also reported that parents who attended information evenings did not change their view as they had already made a final decision .