As described in the study protocol,16 this study was guided by an Indigenist Research approach, defined as ‘research by Indigenous people whose primary informants are Indigenous people and whose goals are to serve and inform the Indigenous struggle for self-determination’.17 The project was also guided by an ecological model for health promotion,18 which views health behaviour as a combination of factors that relate to intrapersonal, interpersonal, institutional, community and public policy.

Reporting follows the Consolidated criteria for reporting qualitative research (see online supplemental file 1)19 including the Consolidated criteria for strengthening reporting of health research involving Indigenous peoples (see online supplemental file 2).20

As described elsewhere,16 a steering committee made up of Aboriginal and Torres Strait Islander people with expertise and experience in Aboriginal and Torres Strait Islander health and research was formed for the duration of the project. The steering committee provided feedback and guidance across all stages of the project. This ensured that the project was culturally safe and appropriate to meet the needs and values of Aboriginal and Torres Strait Islander people and communities. Steering committee members were remunerated for their time and invited for coauthorship.

The research team acknowledges the significant role of identity and reflexivity in conducting qualitative research and research with Aboriginal and Torres Strait Islander peoples. The multidisciplinary team consists of Aboriginal and Torres Strait Islander researchers (AM-D, TB, GG, LJW and the steering committee—EW, VC, SE, FL, and CR) and non-Indigenous (KA, JB, JC, and AJ) people with expertise in cervical cancer elimination (AM-D, TB, LJW, JB, GG, JC, AJ), community engagement (LJW, GG, steering committee) and qualitative research (AM-D, TB, KA, LJW, AJ, GG). Further details providing the research team and the steering committee reflexivity statements are reported elsewhere,21 collectively sharing a passion for improving health among Aboriginal and Torres Strait Islander peoples. The steering committee was a crucial element of our research governance and provided valuable knowledge and guidance informed by their professional backgrounds and lived experience as Aboriginal and/or Torres Strait Islander peoples.

We use ‘providers’ to refer to individuals involved in delivering and coordinating school immunisation programmes, such as nurses and immunisers, programme coordinators, council coordinators and state health department representatives. We use ‘school staff’ to refer to individuals working within the education system who are involved in supporting and facilitating the school immunisation programme, including teachers, school nurses, administration staff, school principals and student support staff. We use key informants to refer to both providers and school staff collectively.

Provider and school staff recruitment was purposive and used a snowballing approach, following consent provided by school principals for schools to participate in the study. As described elsewhere,16 school recruitment aimed to achieve a maximally diverse sample across Queensland (including metropolitan, regional, remote districts, government, independent schools and varying school size). Potential participants were initially identified by the nominated school representative at each participating school. The school representative provided advice on local protocols and appropriate research approach, or this was sought from other Aboriginal and Torres Strait Islander staff members. The research team approached key informants and informed them about the study that was taking place at the school. The school representative then passed on their contact details to the research team if they expressed interest in participating. Because participants chose to take part by contacting the research team, we were unable to record how people declined to participate. The research team provided all formal study information and official invitations to prospective participants via email and/or phone. Participants were also identified via the SIP coordinators, Queensland education contacts, research team and steering committee contacts, through a search of state government websites. Recruitment continued until all identified potential participants had been invited to participate. No participant dropped out or withdrew statements throughout the duration or completion of the project. As we aimed to recruit a maximally diverse sample, data saturation was not a priority. However, when analysis commenced it was clear data saturation had been achieved.

Research occurred between October 2020 and May 2022. While Yarning methods were used for other participant groups in the larger project, few key informants in this substudy identified as Aboriginal and Torres Strait Islander people and so semistructured interviews were used. Whenever possible, interviews were conducted privately in-person and scheduled to coincide with the SIP clinic. Interviews were also conducted over the phone or online via Zoom. All interviews were audio-recorded. Field notes were also collected during observation of the school’s immunisation clinic to provide context for the interviews (reported elsewhere21).

Participants provided either physical signed consent, audio-recorded verbal consent or consent via email and completed a brief demographic survey that included questions about their age, sex/gender, Indigenous status, current role, length of time in role, work experience, level of education and qualifications attained.

The researchers introduced themselves and the research topic before commencing the interview. An interview topic guide (online supplemental file 3) was used for semistructured interviews; the topics included the programme processes such as consent, programme engagement with Aboriginal and Torres Strait Islander adolescents and caregivers, information, education and promotion of the HPV vaccine, and factors that impact uptake and completion of the HPV vaccine course among Aboriginal and Torres Strait Islander adolescents. Experienced Aboriginal and Torres Strait Islander researchers (AM-D, LJW and TB, all women) conducted the interviews, ranging from 20 min to 45 mins long.

A transcription company transcribed interviews verbatim. Transcripts were not returned to participants for comment or correction as it was not logistically feasible. No participant dropped out or withdrew statements from the study throughout the duration or completion of the project. Completed hard copy forms were kept in a locked cabinet, and digital files were stored on secure servers, accessible only to the project team.

Analysis commenced after data collection concluded. Data from interviews and field notes were imported into the software NVivo (V.13) to facilitate analysis. Thematic analysis was used through an iterative process led by Aboriginal and Torres Strait Islander investigators (AM-D, TB and LJW) and supported by an experienced non-Indigenous qualitative researcher (KA). First, AM-D, TB and LJW created initial codes by coding three transcripts each, discussing emerging concepts and cross-checking coding for consistency. Codes were generated inductively from the data and deductively using an ecological model of health promotion.18 Once codes were agreed on, AM-D created a coding structure reviewed by TB and LJW, followed by a coding summary of the initial three transcripts, which was reviewed by TB, LJW and KA. The codes were finalised and AM-D coded the remaining 15 transcripts. Coding summaries were reviewed by TB, LJW and KA before use in interpreting the data and themes, with the final version written by AM-D.

In line with Rigney’s Indigenist Research approach and as outlined in the Reflexivity section of this paper, it was important that the conceptualisation, data analysis, interpretation of findings and writing were led by Aboriginal and Torres Strait Islander researchers. Under the governance of an Aboriginal and Torres Strait Islander steering committee, these principles were supported and upheld by all researchers on the team. Steering committee meetings were held several times a year throughout the duration of the project. Members provided valuable guidance on the interview guide, ideas for school reciprocity and interpretation of results. Additionally, members had the option to be recognised as coauthors. These principles were particularly important to apply in this subanalysis from a predominantly non-Indigenous key stakeholder group, to appropriately unpack the power dynamics, and structural barriers discussed and to ensure that the focus was on delivering the vaccine to Aboriginal and Torres Strait Islander adolescents.

The application of an ecological model of health for this analysis, allowed for an exploration of factors occurring at the individual level (immunisation providers and school staff knowledge and attitudes), interpersonal level (relationships between families, schools and immunisation providers), institutional level (school policies, programme design, coordination between sectors) and broader system-level contributors (historical and colonial legacies, public health policies). Preliminary findings were reported back to the Aboriginal and Torres Strait Islander Steering Committee and feedback incorporated into the findings.

As this project involves a public health programme, there was no patient involvement in this study; however, the public were involved in several ways. HPV vaccination was identified as priority in the National Aboriginal and Torres Strait Islander Cancer Framework,22 which had Aboriginal and Torres Strait Islander leadership and community consultation. This project was conducted with the guidance and collaboration of an Aboriginal and Torres Strait Islander Steering Committee. A key aspect of this involved their participation in interpreting the findings from the interviews with the research team. Recognising their valuable expertise and role as knowledge holders, all steering committee members were offered authorship. Further details of the involvement and governance of Aboriginal and Torres Strait Islander people in this project are provided in online supplemental file 2. We plan to share summaries of the findings of the entire Yarning about HPV vaccination study with participating schools and with individual participants who opted in to receive summaries of the findings.

Table 1

Participant and school characteristics

Programme providers highlighted a need for better communication and coordination between the school clinic coordinator/s and the immunisation clinic providers, citing breakdowns in communication as the main reason for misunderstandings of instructions and inconsistent procedures across the vaccination process. This impacted vaccination delivery in several ways, including the scheduling of clinic visits, complying with venue and clinic requirements and timely management of student vaccination records. Providers highlighted the need for further education of school staff about the vaccination pathway via SIP—from consent through to course completion.

Providers noted that adherence to immunisation health and safety requirements by school staff was inconsistent; additionally, schools frequently described challenges in finding appropriate venues for the clinics to meet safety requirements.

… there’s often a big gap between what we request and the reality of where we’re vaccinated [2828, Nurse Immuniser, Metropolitan].

Providers valued being regarded by schools as competent in their role and understanding the safety requirements of their duties during clinic visits.

I wouldn’t go into a teacher’s class and say, “teach it this way and be done by half past nine.” We’re two professional people together, and when I'm doing clinic and when we’re giving vaccines, the safety side is paramount [2828, Nurse Immuniser, Metropolitan].

Some schools had limited space or capacity to accommodate clinic visits. This was usually due to the small size of the school, building and construction happening on school grounds, walking distance to and from the clinic, and limited amenities like a sink to wash hands. As such, schools sometimes had to facilitate clinic visits in non-ideal venues that were not appropriate for post-vaccination recovery.

So, we were having them go across to another classroom which is over a car park; it’s a big car park. They were like someone needs to escort them over in case they faint and that sort of stuff; it was a long way to walk [1563, Immunisation Coordinator, Remote].

So, we generally like a room with an in and out door. We like to have an area for recovery. We like to have – be able to wash our hands. But seldom [do] we get a sink in the room… normally you have to walk over to the toilets [2828, Nurse Immuniser, Metropolitan].

Two programme providers ran clinics in non-air-conditioned rooms and noted that it was too hot for students, especially during the 15 min recovery period. Other features of the clinic set-up also presented challenges, such as limited privacy for students being vaccinated. Some of the room set ups were too small, had no dividers or designated areas where pupils could be separated by those queuing in the line, those being vaccinated, and those waiting in the recovery area.

It’s not the sort of venue for us to be able to spend huge amounts of time with individual pupils. So, if you have a child that is highly anxious, or adamant they don’t want to have it, we do have limited time to give that pupil [2828, Nurse Immuniser, Metropolitan].

Adherence to clinic venue requirements was paramount for nurse immunisers and programme partners to ensure the safety and comfortability of students, who often felt uncomfortable due to a lack of privacy and other non-optimal venue conditions.

One provider mentioned the challenges of managing student data, particularly for important tasks like confirming vaccination status to link to Medicare records, school transfers or residential address changes and following up on consent forms. They found that some schools were reluctant to provide this information and other basic demographics, even though this is permitted in legislation and communicated in the SIP information booklets provided to the schools.

… my biggest problem is the delay in data entry, and the delay comes from not having the information of students who don’t return the form, and the school’s reluctance to give that to me, even though I do have legislation backing me, saying that I am allowed to ask and receive this information… I also included the Public Health Act, and I still get push back from that… It’s probably just an attitude towards the entire program. Some schools just see it as an inconvenience… It’s good when I have support from the schools and you’re able to achieve things better, but if the school supports it, you notice it in the consent form return rate, like you really do [4156, School Admin Staff, Regional].

Programme providers were conscious of schools with limited capacity to host the clinic visit due to other school demands or activities taking place on the same day. Many providers explained that clinics visits were often rushed and there was not enough time allocated to spend with each student, especially at larger schools or visits that included students for catch-up sessions.

Some schools, they do want you in and out really quickly because we’re affecting their curriculum they’ve got, and we’re just a nuisance to them sometimes. They don’t want us there with kids fainting and different things [3363, Nurse Immuniser, Regional].

A lot of schools get upset if clinics go beyond a certain period of time, even though we do tell them it’s going to take however long as it’s going to take, there are things outside our control with delays and various diverse events from the immunisation, like there’s nothing we can do about that [4156, School Admin Staff, Regional].

This impacted nervous students, who ideally would have received more time from immunisers to address their questions and alleviate concerns. However, due to time constraints, some students chose not to get vaccinated.

Nurse immunisers juggled multiple tasks, particularly on the time-pressured vaccination day, such as managing the students’ emotions, providing information, answering queries, supervising and caring for students’ postvaccination and contacting parents if a student declined vaccination or if a consent form was not returned. However, understaffing and short time allocation for the vaccination clinics negatively impacted nurses’ ability to carry out these tasks.

To be honest, there isn’t time for us, we’re not allocated time to ring all of the parents, and all of the children that we don’t vaccinate… there could be as many as 20 children who don’t get vaccinated, and they would all be sent out a letter from admin. However, with the smaller special schools, if I've got time, I ring. And I can't speak for my colleagues. We’re not told to do that, we’re told, if you can, great. So I try and make an effort, and today I made an effort [2828, Nurse Immuniser, Metropolitan].

Immunisation providers observed a number of disruptions to the SIP usually due to issues around the scheduling of clinic visits. Some schools were unprepared for visits due to mixing up dates or school staff forgetting on the actual day. Sometimes school events and construction work in the school grounds that coincided with visits also disrupted the programme.

They had been notified many times about the clinic. It was on their calendar, but the school – they had forgotten. Because they were having work done, building work, they had sent a load of pupils offsite for sport. And they were children that were to be vaccinated [2828, Nurse Immuniser, Metropolitan].

School staff and programme providers both agreed that connecting Aboriginal and Torres Strait Islander school staff, programme providers or Indigenous community health organisations, with students and their families not long after they have commenced school, is most effective in building rapport and would facilitate engagement in the HPV vaccination programme. Having enough lead time to engage with families was regarded as being beneficial.

…when we're working with Aboriginal and Torres Strait Islander communities, we talk about the three cups of tea; the first time is just the meet and greet, the second time is that you’re now all of a sudden friends, and then the third time is you’re family, we’ll do anything for you. It’s the same situation [with following-up on consent forms]. It needs a longer lead-in time [1662, Student Support Staff, Metropolitan].

One participant reflected that this can be challenging when there is a large cohort of Aboriginal and Torres Strait Islander students, and adequate time and resources are not embedded in the process.

We are sitting at 24 nearly 25 per cent Indigenous now, so the more Indigenous enrolments we have the harder it is with those sorts of things [following up with consent forms]. So having consistency and support absolutely that work in community and with families and with the school is a vital link [1563, Immunisation Coordinator, Remote].

This was particularly apparent in the completion and follow-up of consent forms and supporting Aboriginal and Torres Strait Islander students on vaccination day.

Completion and return of consent forms were highlighted as a major barrier to HPV vaccination. Staff-reported parents feeling overwhelmed by the influx of forms and information sheets at the beginning of the school year. However, this was an issue common to all students attending the school, not just Aboriginal and Torres Strait Islander students.

… something more needs to be done there because it’s not just Indigenous [students who don’t receive the consent form], we have a lot of kids who don’t get it, and for some of the kids, it’s like, “I didn’t bring the form back in time [1172, Immunisation Coordinator, Metropolitan].

Teaching staff and other school staff were usually juggling multiple roles within the school, and involvement in the HPV vaccination clinic was an additional workload. Competing demands were mentioned frequently, with school staff often too busy, understaffed or not allocated enough time to efficiently carry out tasks involved in coordinating the HPV vaccination clinic, such as providing information and education to students and parents who had questions and concerns. As a result, school staff had very little time to follow-up the return of HPV vaccination consent forms.

… I don’t really have a chance to talk to the kids and say, “Have you brought them back, are you bringing them back?” And ask those questions, I never really have time at the beginning of the year to really stop and pay attention to what is going on there” [1172, Immunisation Coordinator, Metropolitan].

If I had a greater timeline, that would be really helpful. The turnaround time was quite short this time, but it would be about engaging the community elders and those health support networks that are already out there and bringing them in to increase the validity [of HPV vaccination]… So any opportunity to bring the community in, then capitalising upon that, but the lead time is probably the biggest thing [1662, Student Support Staff, Metropolitan].

Some providers and school staff followed up on consent forms via home visits, particularly for Aboriginal and Torres Strait Islander students, in small schools or cohorts. Several schools relied on Aboriginal and Torres Strait Islander school staff to follow up on consent forms by organising home visits and check-ins with Aboriginal and Torres Strait Islander students and their families. This method was also utilised to follow up with students who had missed vaccination due to absenteeism, suspension or other circumstances. One school relied on an Aboriginal and Torres Strait Islander community sport organisation to follow up on consent forms with students. The organisation dropped students to and from school and talked with caregivers at home, so forms could be returned sooner. All staff used existing community networks (eg, Aboriginal and Torres Strait Islander health workers) to connect to caregivers to answer any questions or concerns, assist with completing the consent forms and/or collecting the forms. This was beneficial for caregivers with a low literacy level or those who were simply busy.

So that’s the value of having our health worker workforce, they are just amazing, they know their communities [5274, School Nurse, Remote].

Some participants observed that the return rate of consent forms was highest when teachers took strong initiative to follow-up and encourage students to return them. This often occurred during roll call in class or through home visits, but its effectiveness was determined by the teachers’ attitude and their ability to take on this responsibility.

… a lot of teachers are on the ball, and demanding the form comes back. So, we’ve noticed that’s worked a bit better than (in) previous years, we’d just hold a parade, hand out the forms at the parade, [and] hand them into the office. -- We haven’t applied more pressure because there’s a lot of things that we’re asking teachers to do, so we have to value it [SIP], I think more [3276, Immunisation Coordinator, Regional].

One school staff member shared their experience with some Aboriginal and Torres Strait Islander students facing complex living arrangements or family situations. Factors such as disturbances at home and parents working long hours made it challenging for school staff to conduct home visits.

…we also have quite a few single parents. We also have a lot of kids who are having to parent themselves and little brothers and sisters because their parents are working so hard, and they’re going to work at 6, and getting home at 7 o’clock at night [5285, Student Support Staff, Remote].

These living realities caused challenges for parents receiving the consent form and returning the completed form, which could affect HPV vaccination uptake among Aboriginal and Torres Strait Islander adolescents.

Aboriginal and Torres Strait Islander school staff went out of their way using personal resources and time to ensure consent was received. For boarding school students, this could include meeting with caregivers at the airport or train station and hand-delivering/collecting consent forms. Other methods of collecting consent forms for non-boarding schools were pop-up stalls in shopping centres and in community hotspots where families could drop off consent forms or ask questions—reducing the cost of transport and minimising reliance on the adolescent to take home the form, have it signed and return it.

I'm really big on meeting as a team around a young person, the schools can sometimes fall in that trap of, well, you’re referred there, and then you’re referred there, and you’re referred there. But I know that even our parents don't like that, because a lot of our parents’ experience that out there with agencies. So, I say, no, we’re the one-stop shop. We can do X, Y, Z, and go above and beyond, whatever you need. Even transporting for lifts for parents, for kids. And we don’t get a car. It’s our personal car [4874, Student Support Staff, Remote].

Some school staff promoted HPV vaccination and return of consent forms via the school app, school newsletter and school forum pages on social media platforms such as Facebook. They found that many caregivers preferred online communication about vaccination and that this increased overall engagement and return of consent forms. Paper-based consent forms were still emphasised as the preferred method at one rural school, where the network in this region is unreliable.

Aboriginal and Torres Strait Islander school staff were aware that their presence in these students’ lives was important and were committed to being a culturally safe figure and/or support person.

It’s not just about learning stuff in the classroom. This is the safe spot. Because we even find after the weekend, every drama that happened at home, kids will divulge after the weekend. So, this is a safe place for them, especially for us too, we must be the safest people on the planet. Because they come to us with all of these things, baggage, first thing on a Monday morning and that sort of thing. So, if they know that the school is not just about books and reading, it’s also around health and wellbeing [4874, Student Support Staff, Remote].

One school staff member highlighted that this engagement should follow through to vaccination day, so that students are met with a familiar face on arriving at the clinic. In particular, having Indigenous student support staff at the clinic is helpful as they are generally perceived as more ‘relaxed’ rather than ‘control figures’ who may punish certain behaviours.

I know with some of the Indigenous kids, they don’t like interacting with admin. Even if they’re not troublemakers and they’re not getting into trouble, just that authority figure, they don’t like sometimes if there’s no good relationship. So having the non-teaching staff present, and the non-admin people I think has been really helpful [1172, Immunisation Coordinator, Metropolitan].

The presence of Indigenous and non-Indigenous teacher aids, chaplains and school nurses at the clinic on vaccination day was common. Both school staff and programme providers felt that it was important for Aboriginal and Torres Strait Islander students to see a familiar face, especially those students who presented as anxious, had a fear of needles or were prone to fainting. The presence of these staff provided more opportunities to check-in with Aboriginal and/or Torres Strait Islander students who were second-guessing receiving the HPV vaccination postconsent and allowed them to feel more comfortable with the process.

The importance of supporting teachers and the education workforce involved in delivering vaccination is a key learning from HPV implementation globally24–26 and was an important finding from this study. We found variation in capacity of staff to support HPV vaccination pending different characteristics such as school support, smaller student cohort, early coordination in the school year which enabled teachers’ time to connect with carers to build rapport, follow-up on consent forms through home visits and spend more time discussing HPV information with students, allowing them to answer questions more effectively and are reflective of previous findings.27 In line with current findings,3 strong initiative and efforts from both school and delivery staff were seen to be the main drivers of high return of consent forms, and increased uptake; however, stakeholders reported the negative downstream impacts of reduced staff capacity on adolescents receiving their vaccination. Schools relied on Aboriginal and Torres Strait Islander school staff to follow up consent forms with Aboriginal and Torres Strait Islanders students. Despite staff capacity, Aboriginal and Torres Strait Islander school staff and other student support staff were self-driven and committed beyond their usual roles and responsibilities, doing many home visits to follow up on consent forms or assist caregivers with filling out consent forms. School staff must continue to be supported at all phases of the vaccination pathway through ‘whole school commitment and involvement’3 ^{p. 9} and systems must be responsive to these needs.

Programme providers’ effectiveness relies heavily on schools’ adherence to venue and clinic setup guidelines and allowing sufficient clinic time, as noted in prior studies.3 28 Schools should aim to follow room requirements to ensure the safety and privacy of students during vaccination. Our findings suggest that school staff supporting the programme would benefit from additional education on SIP guidelines to meet health and safety standards, including time allowances, as this has been an ongoing issue.27 Adolescents in the SIP should be afforded the same baseline standards as any other vaccination clinic.

To lessen the load on school staff, particularly Aboriginal and Torres Strait Islander staff balancing cultural and organisational roles, schools could benefit from clearer role descriptions, increased support and designated staff for consent follow-ups. Programme success depends on the capacity of both school staff and providers and ultimately this means that schools and Queensland’s education system must place value on, and devote resources to, supporting the SIP as an important public health programme.

This study was guided by Nurungga Professor Rigney’s Indigenist research approach17 and as such was led and guided by Aboriginal and Torres Strait Islander researchers, a steering committee and prioritised the knowing and experiences of Aboriginal and Torres Strait Islander peoples. To the best of our knowledge, there are currently no other published studies to date which examine stakeholder perspectives of HPV vaccine uptake among Aboriginal and Torres Strait Islander adolescents and caregivers via the SIP.

While the study was limited to Queensland, a similar methodology can be employed to conduct further external studies or adapt these recommendations to other States and Territories. We recognise that there are diverse school settings and so the challenges presented, and potential solutions will vary. Governance structures and funding allocation also differ between states and territories, so recommendations must be tailored to the specific needs and capacities of different communities. As such, additional research in other states is required to capture the perspectives and experiences of school staff and providers, and how uptake is impacted in other cohorts of Aboriginal and Torres Strait Islander adolescents and their caregivers.

As noted in the Recruitment and Participants section, Principals and Teachers were invited to participate in the study. We were unable to state how many, due to the small sample size being potentially identifying. Therefore, they are represented by the category ‘school staff’. As qualitative data strives for richness and depth of data rather than representativeness achieved through large sample sizes, the sample size adequately captures a wide range of relevant views.

Data collection for this study took place through 2020 and 2021 at the height of the COVID-19 pandemic, which caused major international, national, state, local and individual impacts to day-to-day life. The COVID-19 vaccine rollout in 2021 received major media attention and contributed to public and online debate around its safety and efficacy.15 This context provided the research team with real-time insights from key stakeholders about the perception of the COVID-19 vaccine and the HPV vaccine among not only adolescents and caregivers during a polarising period, but also their perspectives on navigating the SIP during a particularly difficult time. The COVID-19 pandemic interrupted various research activities, particularly some interviews with school staff and programme providers that were initially scheduled during clinic visits. As such, findings from this period do not represent a ‘normal day’, however, still provide insight into how students, schools, providers and systems were impacted by a phenomenon that, in future, could become more frequent.

We provide a number of recommendations that support the current literature on stakeholders’ perspectives of HPV vaccination of Indigenous adolescents. Recommendations previously identified in an impact evaluation of the national HPV vaccination programme in Australia and international literature, align with the findings3 15 24 raised by stakeholders in this study. As previously mentioned, further research is recommended to explore state-specific differences in the school-based HPV vaccination programme. The following recommendations can be highlighted to ensure ongoing, improved HPV vaccination for Aboriginal and Torres Strait Islander students in the SIP:

• Develop additional culturally appropriate resources to support school staff and programme providers to provide information and education to Aboriginal and Torres Strait Islander families.

• Implement flexible models of consent, guided by the needs of the local community.

• Ensure additional catch-up clinics are scheduled to avoid missed opportunities to vaccinate as a result of the one-dose schedule.

Not applicable.

Ethical approval for the study was provided by the Human Research Ethics Committee (HREC) of the NT Department of Health and Menzies School of Health Research (2019-3484), Aboriginal Health and Medical Research Council HREC (1646/20), Australian National University HREC (2020/478), Townsville HHS HREC (HREC/QTHS/73789), the University of Queensland HREC (number 2021/HE002276), and Far North Queensland HREC (#HREC/2021/QCH/78996). Site-specific approval to conduct research with QLD Health staff was provided by Townsville HHS Research Governance Office (SSA/QTHS/73789), and Cairns and Hinterland Health and Hospital Service (SSA/2021/QCH/78996).