The role of school-based health education in promoting childhood and adolescent vaccination: A systematic review and Meta-analysis

BACKGROUND: Childhood and adolescent vaccination is a cornerstone of public health, yet coverage has stagnated or declined in several regions, partly due to vaccine hesitancy. Schools offer a unique setting to promote vaccination by reaching children and adolescents during formative years. This systematic review and meta-analysis aimed to synthesize evidence on the effectiveness of school-based health education interventions in improving vaccine-related knowledge, attitudes, intentions, and uptake. METHODS: Following PRISMA guidelines, we searched six databases up to August 2024 for interventional studies evaluating school-based educational programmes targeting students aged 6-18 years. Randomized controlled trials and quasi-experimental studies assessing outcomes related to vaccine knowledge, attitudes, intention to vaccinate, or uptake were included. Studies focusing on COVID-19 vaccination were excluded. Risk of bias was assessed using validated tools. A random-effects meta-analysis was conducted for HPV vaccination uptake. RESULTS: Thirty-eight studies (1985-2024) were included: 9 RCTs/cluster-RCTs, 14 controlled quasi-experimental studies, and 15 pre-post studies. HPV vaccination was the most frequently studied vaccine (26/38). Most interventions significantly improved vaccine knowledge, while effects on attitudes and intention were less consistent. Eleven studies assessed vaccine uptake, with most reporting post-intervention increases. Meta-analysis of randomized trials showed a significant effect on HPV uptake (RR 4.18, 95% CI 1.41-12.37), although heterogeneity was high and methodological quality varied. CONCLUSIONS: School-based health education appears to improve vaccine knowledge and may contribute to increased uptake, particularly for HPV. However, evidence is limited by heterogeneity and risk of bias. More rigorous, theory-informed, and sustainable whole-school approaches are needed.