Vaccination Requirements for Child Care, School, and College Attendance

Part I. Community Guide Update and Rationale for Intervention

Table 1: Summary of Recent Interventions:

Community Guide Update and Rationale for Intervention:

Vaccination requirements for child care, school, and college attendance is currently recommended by the Community Preventive Services Task Force as of 2016 due to evidence suggesting it increases vaccine coverage, as well as benefiting ethnic and racial minorities. This review is based on 32 different studies done from 1980 to 2015, only one of which focused on colleges; however, it is probable that we will see increased vaccine uptake in colleges as well. Despite this, there are three aspects of vaccination requirements that may influence vaccination rates: 1) geographic clustering of under-immunization, 2) inconsistent enforcement of requirements, and 3) the relative ease of obtaining nonmedical exemptions. It is recommended that we increase the difficulty of receiving a medical exemption pass, as well as making enforcement and monitoring more clear and consistent.

The study published by Rehn et al. focuses on increasing HPV vaccinations in Swedish girls by making offering these vaccinations to a catch-up group. This study was done in all counties in Sweden, focusing on girls born between 1993 and 1998 with a three-year follow-up. All primary health-care centers provided these vaccinations, but only four schools did so. The schools that did showed an increase in HPV vaccination compared to counties in which no schools offered these. This is indicative of school’s important role in children’s vaccinations and how children receive them. Based on this, we recommend an increase in school’s participation in childhood vaccinations; however, we cannot directly apply this to vaccination requirements in schools.

The article published by Saad et al. analyzed rates of nonmedical exemptions versus pertussis incidence data for children 18 and younger. States with no nonmedical exemptions were compared to states with religious nonmedical exemptions and states with both personal belief and religious nonmedical exemptions. The process of getting a nonmedical exemption was also compared, ones that were rated as difficult were compared to those rated medium and easy difficulty. States with an easy process of getting a nonmedical exemption or personal belief nonmedical exemptions were associated with a higher incidence of pertussis. Though this study focuses only on pertussis incidence, it is reasonable to assume there might be a similar incidence in other vaccine-prevented diseases. This study recommends banning nonmedical exemptions, if not making it more difficult to receive them.

The study by Zimmerman et al. studies how the 4 Pillars Immunization Toolkit (a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress) affects vaccine uptake. 20 pediatric and family medicine centers were tasked to implement the toolkit. Vaccine uptake and maintenance were measured in children aged 6 months to 18 years. During this intervention, vaccine uptake increased by 8% and maintained. This study recommends a more involved approach to children’s vaccinations, especially those that are recommended when it comes to healthcare providers.

Part II. Theoretical Framework/Model

We will be exploring the effects of nonmedical exemptions on childhood vaccination and sickness, so this will be explored using the Health Belief Model. The Health Belief Model attempts to explain and predict health behaviors. It focuses on the attitudes and beliefs of individuals. We believe this is the best fit for nonmedical exemptions and vaccinations, as many vaccinations (such as Hepatitis A and Measles, Mumps, Rubella) are free with insurance with no copayments as required by law. Many scientists support vaccinations and their benefit to society. However, the United States still has an issue with vaccine uptake and, recently, nonmedical exemptions leading to outbreaks of diseases prevented by vaccinations. There are five main constructs, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action.

Constructs:

Perceived susceptibility, how much one believes they are susceptible to a disease, can affect how likely one is to get a vaccine. For example, parents may not get their children the HPV vaccine, due to the belief that their child will not have sex, or at least not having sex at the moment. more on this

Perceived severity, how severe a person believes a condition is, may also play a role in vaccination. A parent who has never seen pertussis in their lifetime may be under the impression that it is not that bad, after all it doesn’t get the news coverage or shows that smallpox does. Similarly, someone who is unfamiliar with diseases may believe the black plague is very severe and a death sentence, when most times it can be cured with antibiotics.

The amount of nonmedical exemptions also depends on the difficulty of getting a nonmedical exemption, and how often a nonmedical exemption has to be renewed, which can be applied to the construct of perceived barriers to getting a nonmedical examination. more on this

It will also be affected by the general attitude toward vaccination. Nonmedical exemptions tend to be clustered in groups, showing that it may be partially due to that area’s general outlook on vaccinations. This may be caused by the belief that the vaccination causes harm, or does not work. People who don’t vaccinate may also think it is better for their immune system to fight off diseases. Both of these examples can be seen as perceived benefits to receiving a nonmedical examination. Sickness due to not being vaccinated can depend on how many people are not vaccinated in the area.

Diagram of Conceptual Model:

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

Target Population:

Our intervention will target areas in which there is a high amount of nonmedical exemptions in California. These areas face a greater risk of disease due to their high amount of unvaccinated children, which tend to be white, middle-class Americans. We will be targeting children aged 0 to 10 who live in these areas, focusing on white, middle-class Americans, because most vaccinations for severe preventable diseases such as measles are scheduled before kindergarten in the United States.

Intervention Setting:

The weekly talks and discussions given by trained volunteers will be done in various key locations in the community, specifically churches, schools, rotary clubs, etc. These places will be easily accessible and comfortable places for the parents while also still acceptable places to learn. Talks between the parent and a doctor or public health professional will take place in the office of the doctor or public health professional. These offices will help parents feel more comfortable in a one-on-one discussion with a trained professional.

Table 2: Intervention Methods and Strategies:

Table 3: Program Logic Model:

Intervention Hypothesis:

By changing policy so that nonmedical exemptions are either more difficult to receive or outright banning them will increase the perceived barriers to getting a nonmedical exemption. However, increasing lectures with volunteers will increase perceived benefits of getting vaccinated and increasing personal talks with doctors and public health professionals will increase the perceived severity and susceptibility of diseases prevented by vaccinations.

Causal Hypothesis:

Changing policy so that nonmedical exemptions are not allowed will decrease nonmedical exemptions and thus increase vaccinations by increasing perceived barriers to getting a nonmedical exemption. However, this will not increase knowledge of vaccinations or vaccinations that are not required by schools.

If we changed policy so that nonmedical exemptions are more difficult to get via increasing paperwork, increasing the process, and/or increasing how often a nonmedical exemption has to be renewed will increase vaccinations by decreasing nonmedical exemptions. We expect that increasing the difficulty of getting a nonmedical exemption (through such methods as increasing paperwork, increasing the process, or increasing the frequency it has to be renewed) will decrease nonmedical exemptions, especially for parents who are not as strong in their belief in the risks of vaccinations as others. However, we expect banning nonmedical exemptions from public schools will decrease nonmedical exemptions more so as it will take care of any parent who wishes to not get their child vaccinated, except those who are so strong in belief that they will place their child in a private school (who may take their child unvaccinated) or even homeschooling them. This method would increase vaccine uptake, but may actually increase situations in which there are many children in one localized area who are not vaccinated, as these strongly-willed parents will send their unvaccinated children to one place. This also does not increase the knowledge of vaccinations in these parents.This is not expected to increase knowledge of vaccinations or vaccinations that are not required by the schools, however.

Increasing lectures given by trained volunteers around the community is expected to lead to an increase in all vaccinations, including those not required by schools, and a decrease in nonmedical exemptions.

Increased personal talks from doctors and public health professionals will lead to an increase in vaccinations, including those that are not required in schools, and a decrease in nonmedical exemptions.  This seems like a good method to increasing vaccinations, which include vaccines that are not typically required by schools, such as the HPV vaccination.

Smart Objectives:

Goal 1: Increase in perceived severity and susceptibility of diseases prevented by vaccinations

Objective 1: After intervention implementation, 70% of parents will pass a test on different diseases prevented by vaccinations with a score of at least 75%

Objective 2: At 4-month follow-up, parents will show an average of 20% increase in a survey on perceived risk of diseases prevented by vaccinations

Goal 2: Increase in perceived benefits of vaccinating a child

Objective 1: After intervention implementation, parents respond more positively in a survey to vaccinations by 25% on average

Objective 2: at 4-month follow-up, the percentage of parents who respond more positively in a survey to vaccination by 25% on average will not have decreased by more than 5% than reported after intervention implementation

Goal 3: Increase in perceived barriers to nonmedical exemptions

Objective 1: During the course of our intervention, 50 senators or house of representatives for the state of California will be contacted in order to push for increasing the difficulty of nonmedical exemptions or outright banning them.

Part IV. Evaluation Design and Measures

Table 4: Stakeholder Roles:

Evaluation Design: Group Randomized Control Trial

R O1 X O2 O3 (Intervention group A)

R 01 X O2 O3 (Intervention group B)

R 01 X O2 O3 (Intervention group C)

R O1 O2 O3 (Control group)

[O1 = pre-test and pre-survey, O2 = post-test after intervention, O3 = post-test and post-survey at 16 weeks]

Intervention Group A: Lecture from trained volunteers about vaccines and their elected senator and representative contacted about nonmedical exemptions

Intervention Group B:Personal talk with health care provider (such as their doctor) and their elected senator and representative contacted about nonmedical exemptions

Intervention Group C: Both lecture from a trained volunteer about vaccines and a personal talk with their health care provider

Control Group: Will continue with normal education on vaccines

Threats to Internal Validity:

We will randomize groups by county so that parents of students will be less likely to cross contaminate. These groups should face similar threats to internal validity, but we will conduct a pre-test analysis in order to test how similar these groups are before our intervention started.

Information Bias: Other Sources of Information:

Besides our intervention, there are many sources of information about vaccines that a parent can go to. These sources may highlight the benefits of vaccinating or focus on the negative aspects or theories on vaccination. A parent may be actively seeking this information by going on the internet or t0 the library, but equally likely is that a parent may be simply watching the news or browsing a news website, as vaccination and diseases are both hot topics for journalists. However, it will be hard to keep parents from talking to their health care provider on their own agenda (not managed by us) or picking up brochures or information from the internet, so we must address this by asking in the surveys to account for this.

Timing Bias: Outbreak of Disease Prevented by Vaccination:

Over the course of our intervention and afterward, we must be aware of outbreaks of vaccine-prevented diseases that occur. We cannot control these outbreaks, but we must consider it if this does occur, as it will likely cause an increase in vaccinations that we will falsely contribute to our intervention.

Mortality/Attrition:

As in all interventions and studies, there is a chance that participants will die or simply lose touch with us. We hope by contacting parents initially through their children’s school, we will be less likely to lose touch with these parents. Additionally, the settings of these interventions should contribute to less attrition as their contact information should be available. We will be looking at our pre-test data to make sure there is not a difference in drop-out rate between our interventions.

Testing:

By using a pre-test and post-test, we run the risk of setting up parents to look for the information we tested them on in their lectures and/or personal talks. This may cause post-tests to have better results even if the intervention was not effective. By using a pre-survey and post-survey, we may also cause parents to think more critically about their answers on their pre-survey before their post-survey, perhaps changing their answers simple due to being given this survey instead of our intervention.

Table 5: Summary of Measures:

Part V. Process Evaluation and Data Collection Forms

1. Provide the following data collection forms for monitoring the program process. More than one form may be submitted for a given category, but all forms must be clearly labeled. (18 points)
   1. Recruitment and enrollment – how will you track who you invite to participate in your intervention and who actually takes part?

School recruitment:

Vaccine Uptake Program in Children

School Recruitment Letter 

Dear _______________,

The University of Georgia’s School of Public Health would like to invite you to be part of our vaccine uptake program, which aims to increase childhood vaccinations in ages 0 to 10. This program includes lectures and small group sessions conducted over a period of two weeks. If you are interested in this program and would like to learn more, please join us on June 4, 2016 at 7 pm at the University of Georgia’s Health Sciences Campus at Russel Hall room 255.

You can also contact us by calling 1800-555-VACC or at Vaccinechildren@uga.edu.

School Enrollment Form:

Schools that sign up for this program will then send out this letter with the children to their parents:

Dear Parent/Guardian,

In partnership with (school name), we are hosting a vaccine educational program, which we would like to invite you and your child to partake in.

As part of the program, you will be participating in (lecture and/or talk with doctor depending on which group they’re in). This will be done at school at 5 pm for two Tuesdays in a row. You and your child will receive assessment tests before your program, afterwards, and two months after this program is complete.

Please fill out the form below if you are interested in participation.

For more info, contact vaccinechildren@uga.edu.

Student name: _____________________________________________________

DOB: _____________

Parent/Legal guardian name: ______________________________________________________________

Doctor Participation form for personal talks with family doctors:

Dear _______________,

The University of Georgia’s School of Public Health would like to invite you to be part of our vaccine uptake program, which aims to increase childhood vaccinations in ages 0 to 10. We would like to invite you to speak with participants of this program about vaccines and the diseases they prevent. If you are interested in this program and would like to learn more, please join us on May 13, 2016 at 7 pm at the University of Georgia’s Health Sciences Campus at Russel Hall room 255.

You can also contact us by calling 1800-555-VACC or at Vaccinechildren@uga.edu.

We will also contact the doctors via phone in order to get the most doctors on board for counties that will be given personal talks with doctors.

Volunteer Participation Form:

Dear _______________,

The University of Georgia’s School of Public Health would like to invite you to be part of our vaccine uptake program, which aims to increase childhood vaccinations in ages 0 to 10. We would like to invite you to speak with participants of this program about vaccines and the diseases they prevent. If you are interested in this program and would like to learn more, please join us on May 5, 2016 at 7 pm at the University of Georgia’s Health Sciences Campus at Russel Hall room 255.

You can also contact us by calling 1800-555-VACC or at Vaccinechildren@uga.edu.

School enrollment form

Each Parent will be asked to sign in for the two lectures.

Lecturers will be given this to fill out after each lecture:

Schools that are having personal talks with their doctors will have the doctors fill out this form after the end of our intervention:

And will fill out this form to see how many parents were involved in this implementation:

All schools except the control group will have the state senators and representatives fill out this form after the intervention:

Citations: