Vaccination Programs in Schools and Organized Child Care Centers

Part I. Community Guide Update and Rationale for Intervention

Table 1. Literature Review

After reviewing three studies about vaccination programs in schools and children care centers,  the recommendation for vaccination programs in schools remains as ‘recommended’, however there is insufficient evidence to make a recommendation for vaccination programs in child care centers. The previous recommendations were based on a systematic review that was published in 2000 and in the past sixteen years a lot has changed in regards to vaccination policies and behaviors. There are changes from the previous recommendations set by the Community Preventive Services Task Force.

There are a few reasons why I chose to keep the current intervention strategy as ‘recommend’ rather than update to ‘strongly recommend’. There is evidence to support that vaccination programs lead to higher immunization rates, but there is still not enough evidence in regards to better health outcomes. In one study that assessed influenza vaccination programs in schools, they found children who had received the influenza vaccine were less likely to spread influenza to their household members, less likely to use medications, had fewer hospital visits and were less likely to miss school (King et al., 2006). However in a study that assessed a HPV vaccinations program for middle school girls, there was no follow up period and participants health outcomes were not assessed so there was no way of knowing  how effective the HPV vaccinations were (Stubbs et al., 2014). All three studies found that there were higher rates of immunizations in schools that provided vaccination clinics than schools that did not provide clinics. While having vaccination clinics at schools provides easier access to vaccines, one study found that there are high administrative costs (Daley et al., 2013). They found giving one vaccine can  cost up to $22 and reimbursement rates vary depending on the type of insurance plan people have (Daley et al., 2013). Vaccination plans can lead to better health outcomes, but they can be costly so identifying ways to lower these costs can be very beneficial.

From this literature review, there were many studies that were conducted in school settings, but none were conducted in child care facilities like day cares. While child care facilities are similar to school settings, one can not assume the interventions applied in school settings will have the same effect. Conducting more studies in child care facilities, and implementing interventions that have been used in schools could show the similarities or differences between the two settings. Until there is enough evidence, recommendations for schools and child care centers should be separated. 

Part II. Theoretical Framework/Model

In recent years, American society’s beliefs about vaccinations have dramatically changed. For many people, they have started to believe vaccinations cause autism. This can attributed to the high prevalence of autism among young children. With anti-vaccination beliefs on the rise, getting people, especially parents of young children, to change their beliefs is really important. One way of doing so is by basing our intervention on a theoretical framework. For this intervention, I will be using the Theory of Planned Behavior which ‘explores the relationship between behavior and beliefs, attitudes and intentions’  through constructs such as behavior intention, attitude, subjective norm and perceived behavioral control (Glanz 2005). Even with strong scientific evidence that supports how autism is not linked to autism, people’s behaviors and opinions have been changed due to influences by the media and their surrounding social environment. Changing parent’s behaviors on vaccinations can increase immunization rates and lower their risk of diseases. Emphasizing how beneficial vaccinations and showing how they are not the cause of autism is necessary. Also informing parents the ramifications of not vaccinating their children, could potentially change their minds as well.

Constructs

1.       Behavioral intention is defined as a person’s ‘likelihood of performing the intended behavior’ (Glanz 2005). For this intervention strategy, it refers to how likely parents allow their children to receive or participate in vaccinations programs at schools or child care facilities . Finding the differences in why parents allow or do not allow their children to receive vaccinations could help change the intentions of parents that do not allow their child to receive vaccinations.  Studies found that children were more likely to receive vaccines if the school offered vaccination clinics than schools that did not (Daley et al., 2013, King et al., 2006, Stubbs et al., 2014).  Finding out if reasons such as more access to vaccines or more awareness is leading to higher immunization rates could also influence whether parents allow their children to participate in these programs.

2.       Attitude is a person’s opinion of the intended behavior.There are many factors that can affect a person’s attitude toward a behavior. For example, parents of children who are autistic or are associated with families with autistic children may be more against vaccinations than a parent to a child who does not have autism. Also people who come from different cultures may view vaccinations as a bad behavior due to their upbringings. Changing parents attitude of vaccinations is an important part of this intervention.

3.       Subjective norm is the person’s perception of how other people view the intended behavior. For this situation, this can refer to how peers and families view the act of vaccination. Those who have support from them would more likely to allow their children to receive vaccines.

      4.       Perceived behavioral control is how much control a person has in performing the intended behavior (Glanz 2005).  For the studies where vaccination clinics were offered in schools, parents were required to fill out a consent form in order for a child to receive the vaccines (Daley et al., 2013 , Stubbs et al., 2014).. This behavior could make the parent feel in control since they have the option of not allowing their child to receive the vaccine. This in turn could influence their attitude and behavior intention. Giving parents multiple options is a key component in this intervention.

Figure 1. Diagram of the Theory of Planned Behavior Model

Part III. Logic Model, Causal and Intervention Hypotheses, and Intervention Strategies

Target population

For this program, the target population will be parents of school children between the ages of 5 and 17. Many vaccination programs require parental consent in order to receive vaccines and is one of the reasons why children do not receive them. Among this population there will be a number of socioeconomic status, cultural, and educational differences that can influence their beliefs and participation in vaccination programs in schools. An article looking at why parents refused to give their children vaccines found religious reasons, personal beliefs, philosophical and safety concerns as to why they would not vaccinate their child (Mckee et al., 2016). Understanding these differences among the target population can help form an intervention that addresses all of those concerns.  

The transmission of diseases in schools can be fast and children at these schools are at extremely high risk of developing and spreading them. School children, especially young children, are less likely to practice habits such as hand washing or covering their mouth when they sneeze or cough which can spread the disease and put their classmates at risk of developing the disease. By having parents who do not vaccinate their children, they put many people at risk of many preventable diseases. One study found children who were under 18 were had a higher attack rates of influenza during a 2009 influenza pandemic (Ridenhour et al., 2011). If these children have been vaccinated, those attacks rates may have been lower.

Program setting

The program setting will be at elementary, middle and high schools and child care facilities where immunization rates are low. Interventions would be implemented in schools in low income neighborhoods where people have limited access to health care. The intervention program will also be implemented in an affluent (private) schools. A study found high income whites were more likely to utilize exemptions when it comes to vaccines (Yang et al, 2016). Seeing if there is a difference between socioeconomic status as well as type of education could help tailor the program.

Table 2.  Proposal of Intervention Methods and Strategies

Table 3. Logic Model

Causal hypothesis

Parents of children may choose not to vaccinate their children for a number of reasons. They make lack the knowledge of how vital vaccinations can be and the how easy it is for an unvaccinated child to infect others. Others may have prior knowledge of vaccinations, but may not be up to date or they may support invalid information. For many parents, they could also have a fear of physical or even social problems that may arise after vaccinating their child. There are also instances where parents have limited access or health care/services.

1. Improving parents attitude toward vaccinations will increase their likelihood of participating in vaccination programs in schools and child care facilities.
2. Decreasing/removing social or religious stigmas against vaccinating children will increase immunization rates in schools and child care facilities.
3. Increasing/promoting perceived behavioral control among parents of school children will increase follow up in vaccinations that require multiple doses.

Intervention hypothesis

Information sessions about the vaccination program being conducted in the schools will lead to an increase in the number of parental consents that are collected.  Multiple sessions will be held and will cater to the communities specific needs and interests. Trained staff and professionals will administer the information sessions and will provide information about the importance of vaccinating school children through slides and pamphlets. During these sessions parents will be able to ask questions and address any concerns they may have.

Meeting with leaders of communities and religious groups will lead to improvements in the way the community views childhood vaccinations. Program coordinators can offer supplemental material and even provide lectures to the community . They can work with the community to address any stigmas and find ways to reduce them.  

Requiring parental consent in order to participate in the clinic will lead to greater perceived behavioral control among parents of school children. Making sure parents have the option of participating in the clinics will make them feel like they have more control over the situation. 

SMART Objectives

1. Change parents attitude of vaccinations to be more positive
   1. Outcome objective: By the end of May 2017, the number of parents whose attitudes about child vaccinations changed from negative to positive will increase by 35%.
2. No social stigma against vaccinating children.
   1. Outcome objective: The number of parents who view childhood vaccinations as a socially acceptable task will increase by 15% by the end of May 2017. 
3. Greater perceived behavioral control among parents of school children.
   1. Outcome objective: There will be a 40% increase in the number of parental consents collected from the first clinic to the fourth clinic by the end of May 2017 for students who have had no prior vaccinations.

Part IV. Evaluation Design and Measures

Table 4.  Role of Stakeholders in the Intervention program

Study Design

Outcome evaluation design: Quasi experimental study design with a non-random comparison group

Scientific notation

O      X      O   (parents who allow their child to be vaccinated)

O      X      O  (parent who do not allow their child to be vaccinated)

Studies would be conducted each of the following locations;

1. Child care facility
2. Elementary school (k-5)
3. Middle school (6-8)
4. High school (9-12)

Schools and child care facility will be chosen at random from one specific county.

Threats to Internal Validity

Bias and confounding are potential threats to the internal validity of the evaluation.  

Selection bias may occur when choosing schools to participate in the program. Schools in the same county can vary depending on location as well as the communities that inhabit the area. There might be more of one race in the area and socioeconomic classes can vary depending on the region. This could affect the results of the program and in turn this type of study not generalizable to other schools in different counties. In order to reduce selection bias, schools will be randomly selected.

Information bias may occur depending on where the programs are being held. Staff may have to approach young children differently than they would older children. Having a consistent protocol that is sufficient at all locations is crucial.

While this study will take into account confounding factors like socioeconomic status and race, there may be other factors that are not as apparent and may have an confounding effect. Controlling for these factors during data analysis will help show the true relationship between the intervention program and outcome of interest.  

Table 5. Assessing the Reliability and Validity of the Short- term outcomes

*surveys were not administered in school settings, and  if they were to used for this program they would modified.

Part V. Process Evaluation and Data Collection Forms

Recruitment/Enrollment Forms

Information Session Invitation

Email will sent to all the parents of children in the school. For parents whose email is not a file materials will be mailed.

Dear Parents,

Your school has been selected to participate in a childhood vaccination program. This program is focused on increasing immunization rates among children by promoting the benefits of vaccinations. During the school year, multiple vaccination clinics will be held at the school. Information session will be held to describe the program as well as include discussions on the importance of the vaccinations provided in the United States. You will have the opportunity to ask questions and address your concerns at the sessions. After attending the session, you as the parent will have the option of allowing your child/children to participate in the clinics.

Please indicate whether you plan to attend the information session or not by using the following link.

www.linktoinvitationforinformationsession.com (will have yes/no, maybe options to mutiple session times and dates)

Attached is information about the program as well as information about what vaccinations that will be offered during the clinics.

Thank you for your time and we look forward to seeing you at one of our information sessions. If you have any questions, please contact us by email or by phone.

Sincerely,

Program Coordinator

Vaccination Clinic Form

After parents attend information they will receive a secondary email to ask whether they chose to participate in vaccination clinic or not.

Dear Parents,

Our records indicate you have attended an information session.

If you intend on participating in the vaccinations clinic please RSVP by using the link below. Details regarding the clinics are listed below. 

RSVP link to clinic

For those who have chosen not to participate, if you could take a few minutes and fill out the linked feedback form to let us know why you made your decision and things we could do differently that would be greatly appreciated.

Link to feedback form

Vaccination clinics will be held after school and appointment times will be emailed. Fill out the attached forms which include medical history as well as which vaccines your child intends on getting and bring them during your appointment. Also, if your child has been previously vaccinated, please bring a copy of their immunization records.

Thank you again for your time and participation. Let us know if you have any questions.  

Sincerely,

Program coordinator

Attrition Forms

Sign in sheet at information session

Sign in sheet at vaccination clinic

Fidelity Forms

Feedback form given to all parents

Dear Participant,

If you attended both information session and the vaccination clinic, please answer questions for both sections. If you only attended one, only answer questions to that specific section.

Information Session

Was the session informative?   Yes   No

Were you able to address your concerns?     Yes   No

Were program staff able to answer your questions?  Yes   No

Prior to session, were you skeptical of vaccinating your child?  Yes      No

Did the session influence your decision to vaccinate your child?   Yes   No

List changes that could improve the session.  

_____________________________________

Vaccination clinic

Why did you chose to vaccinate your child? ______________________.

Did you child have prior vaccinations?  Yes  No

Would you recommend this program to other families?   Yes  No

If there is any changes you would recommend for future clinics, please write below?

__________________________

Forms to be filled out by program staff and/or coordinators

Form used to track timing of sessions

Please check the topics that were covered during each session.

For each session please indicate which topic was discussed the most and which topic was discussed the least. 

Feedback form from program staff

Which topics did you find necessary/useful? _______________

Which topics would you recommend shortening or removing from presentation?__________

Did the sessions run on-time, overtime, or under-time? Circle one

Were the presentations too long or too short?________

Did the presenter do a good job presenting the information?  Yes or No

 If no, please specify why. ________

What are some changes you recommend for the program? ________________

References

Daley, M. F., Kempe, A., Pyrzanowski, J., Vogt, T. M., Dickinson, L. M., Kile, D., . . . Shlay, J. C. (2014). School-Located Vaccination of Adolescents With Insurance Billing: Cost, Reimbursement, and Vaccination Outcomes. Journal of Adolescent Health, 54(3), 282-288. doi:10.1016/j.jadohealth.2013.12.011

Britt, R. K., Hatten, K. N., & Chappuis, S. O. (2014). Perceived behavioral control, intention to get vaccinated, and usage of online information about the human papillomavirus vaccine. Health Psychology and Behavioral Medicine, 2(1), 52-65. doi:10.1080/21642850.2013.869175

Glanz, K. (2005). Theory at a glance: A guide for health promotion practice. Bethesda? Md.: U.S. Dept. of Health and Human Services, National Cancer Institute.

Mckee, C., & Bohannon, K. (2016). Exploring the Reasons Behind Parental Refusal of Vaccines. The Journal of Pediatric Pharmacology and Therapeutics, 21(2), 104-109. doi:10.5863/1551-6776-21.2.104

Opel, D. J., Taylor, J. A., Zhou, C., Catz, S., Myaing, M., & Mangione-Smith, R. (2013). The Relationship Between Parent Attitudes About Childhood Vaccines Survey Scores and Future Child Immunization Status. JAMA Pediatrics JAMA Pediatr, 167(11), 1065. doi:10.1001/jamapediatrics.2013.2483

Ridenhour, B. J., Braun, A., Teyrasse, T., & Goldsman, D. (2011). Controlling the Spread of Disease in Schools. PLoS ONE, 6(12). doi:10.1371/journal.pone.0029640

Stubbs, B. W., Panozzo, C. A., Moss, J. L., Reiter, P. L., Whitesell, D. H., & Brewer, N. T. (2014). Evaluation of an Intervention Providing HPV Vaccine in Schools. Am J Hlth Behav American Journal of Health Behavior, 38(1), 92-102. doi:10.5993/ajhb.38.1.10

Yang, Y. T., Delamater, P. L., Leslie, T. F., & Mello, M. M. (2016). Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California. Am J Public Health American Journal of Public Health, 106(1), 172-177. doi:10.2105/ajph.2015.302926