Understanding reasons for participating in a school-based influenza vaccination program and decision-making dynamics among adolescents and parents

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

OBJECTIVES

We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP).

METHODS

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year.

RESULTS

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

CONCLUSION

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Severe acute respiratory illness surveillance for influenza in Kenya: Patient characteristics and lessons learnt

Background

We describe the epidemiology and clinical features of Kenyan patients hospitalized with laboratory‐confirmed influenza compared with those testing negative and discuss the potential contribution of severe acute respiratory illness (SARI) surveillance in monitoring a broader range of respiratory pathogens.

Methods

We described demographic and clinical characteristics of SARI cases among children (<18 years) and adults, separately. We compared disease severity (clinical features and treatment) of hospitalized influenza positive versus negative cases and explored independent predictors of death among SARI cases using a multivariable logistic regression model.

Results

From January 2014 to December 2018, 11,166 persons were hospitalized with SARI and overall positivity for influenza was ~10%. There were 10,742 (96%) children (<18 years)—median age of 1 year, interquartile range (IQR = 6 months, 2 years). Only 424 (4%) of the SARI cases were adults (≥18 years), with median age of 38 years (IQR 28 years, 52 years). There was no difference in disease severity comparing influenza positive and negative cases among children. Children hospitalized with SARI who had an underlying illness had greater odds of in‐hospital death compared with those without (adjusted odds ratio 2.11 95% CI 1.09–4.07). No further analysis was done among adults due to the small sample size.

Conclusion

Kenya's sentinel surveillance for SARI mainly captures data on younger children. Hospital‐based platforms designed to monitor influenza viruses and associated disease burden may be adapted and expanded to other respiratory viruses to inform public health interventions. Efforts should be made to capture adults as part of routine respiratory surveillance.

What do adolescents think about vaccines? Systematic review of qualitative studies

Adolescence presents a key opportunity to build vaccine-related health literacy and promote vaccine confidence and uptake. Although adolescents are central to vaccination programs, their views around vaccines are frequently underrepresented in qualitative literature. We reviewed qualitative studies to systematically identify and summarize existing evidence on adolescents' own understanding of vaccines and experiences with vaccine decision-making, including self-consent when applicable. CINAHL; Embase; Ovid Medline; and Psych Info database searches were last updated on May 28, 2022. Data pertaining to general study characteristics, participant demographics, and qualitative content were extracted independently by two reviewers and analyzed using textual narrative synthesis. Out of 3559 individual records, 59 studies were included. The majority of the studies were conducted in high-income countries and 75% focused on human papilloma virus vaccines, with the remaining studies looking at COVID-19, meningococcal, hepatitis B and influenza vaccines or adolescent experiences with vaccines in general. Adolescent self-consent was explored in 7 studies. Perspectives from sexual and gender minorities were lacking across studies. Adolescents often had limited understanding of different vaccines and commonly perceived vaccine information to be directed towards their parents rather than themselves. Many adolescents felt school-based vaccine education and information available through healthcare providers were insufficient to make informed decisions about vaccines. While adolescents described obtaining vaccine information from traditional and online media, face-to-face interactions and opinions from trusted adults remained important. Adolescents generally relied on their parents for vaccine-decision making, even when self-consent was an option. A notable exception to this included marginalized adolescents who could not rely on parents for health-related advice. Qualitative literature about adolescent vaccines would be enriched by studies examining vaccines other than the HPV vaccine, studies examining adolescent vaccine programs in low and middle-income countries, and by deliberately eliciting vaccine experiences of adolescent with diverse sexual orientation and gender identities.

Evaluation of Japanese people's perception of risk information for making decisions to receive influenza and rubella vaccinations

BACKGROUND

Generally, vaccination uptake in Japan lags behind World Health Organization targets.

OBJECTIVE

This study aimed to understand how risk information and advice affect intention to receive vaccinations.

METHODS

This study had a within-subjects design. An online survey based on the Health Belief Model was sent to 2501 Japanese individuals (≧20 years) to assess the intention to be vaccinated for influenza and rubella after receiving minor and severe risk information and hypothetical advice about each vaccine. Regression analysis was used to measure changes in intentions to receive each vaccination after being provided with (1) risk information about each vaccine and (2) hypothetical encouragement and discouragement to be vaccinated.

MAIN OUTCOMES

The main outcomes included changes in vaccination intentions from baseline.

RESULTS

Forty-one percent (N = 1030) of those sent the survey completed it. At baseline, 43% and 65% of the respondents intended to have influenza and rubella vaccinations, respectively. Being provided with information about severe risks and susceptibility increased the intention to have the influenza vaccination among females in their 40s. Receiving inaccurate and discouraging information from one's mother significantly decreased the intention to have the rubella vaccination. Women 50 and older were more likely to intend not to have vaccination for rubella. Severe risk information decreased rubella vaccination intention in all age groups, except women in their 30s and 40s (p < .05).

CONCLUSION

For both vaccinations, older individuals demonstrated vaccine hesitancy. This group requires tailored messaging to help them understand their vulnerability (to influenza) and their role in transmission (for rubella) to encourage uptake of essential vaccinations.

PATIENT OR PUBLIC CONTRIBUTION

Members of the Japanese public responded to our online questionnaire on vaccination risk.

Effects of Patient-Centered Communication on Influenza Vaccination and Self-Reported General Health Status among Asian Americans: A Comparison Model for Young/Middle-Aged and Older Adults

Objectives: Asian American subgroups’ influenza vaccination is still below the US standards. This study examined the effects of patient-centered communication (PCC) on influenza vaccination and the general health (GH) of Chinese, Vietnamese, and Korean Americans. A group difference between younger and older adults was investigated. Methods: The 2014–2016 California Health Interview Surveys were merged (Chinese [ N = 1,680], Korean [ N = 514], and Vietnamese [ N = 644]; age 18+; younger = 1,629 and older = 1,209). Two path models (PCC [measured by physicians’ careful listening], vaccination, and GH; PCC [measured by physicians’ clear explanation], vaccination, and GH) were evaluated. Regression maximum likelihood was applied for missing values. Results: Both the first and second models showed good model fit scores (comparative fit index [CFI] = .95, root mean square error of approximation [RMSEA] = .04, and standardized root mean residual [SRMR] = .03; CFI = .93, RMSEA = .04, and SRMR = .03). There were direct effects of PCC on vaccination among younger adults. PCC directly influenced GH for both age-groups. Discussion: A PCC manual for physicians in local or community health centers could enhance both younger and older adults’ influenza vaccination.

Beliefs around childhood vaccines in the United States: A systematic review

BACKGROUND

While childhood vaccines are safe and effective, some parents remain hesitant to vaccinate their children, which has led to outbreaks of vaccine preventable diseases. The goal of this systematic review was to identify and summarize the range of beliefs around childhood vaccines elicited using open-ended questions, which are better suited for discovering beliefs compared to closed-ended questions.

METHODS

PubMed, Embase, and PsycINFO were searched using keywords for childhood vaccines, decision makers, beliefs, and attitudes to identify studies that collected primary data using a variety of open-ended questions regarding routine childhood vaccine beliefs in the United States. Study designs, population characteristics, vaccine types, and vaccine beliefs were abstracted. We conducted a qualitative analysis to conceptualize beliefs into themes and generated descriptive statistics.

RESULTS

Of 1727 studies identified, 71 were included, focusing largely on parents (including in general, and those who were vaccine hesitant or at risk of hesitancy). Seven themes emerged: Adverse effects was most prominent, followed by mistrust, perceived lack of necessity, pro-vaccine opinions, skepticism about effectiveness, desire for autonomy, and morality concerns. The most commonly described beliefs included that vaccines can cause illnesses; a child's immune system can be overwhelmed if receiving too many vaccines at once; vaccines contain harmful ingredients; younger children are more susceptible to vaccine adverse events; the purpose of vaccines is profit-making; and naturally developed immunity is better than that acquired from vaccines. Nearly a third of the studies exclusively assessed minority populations, and more than half of the studies examined beliefs only regarding HPV vaccine.

CONCLUSIONS

Few studies used open-ended questions to elicit beliefs about vaccines. Many of the studies that did so, focused on HPV vaccine. Concerns about vaccine safety were the most commonly stated beliefs about childhood vaccines, likely because studies were designed to capture barriers and challenges to vaccination.

Evaluation of Educational Interventions to Enhance Adolescent Specific Vaccination Coverage

BACKGROUND

In this study, we assessed impact of two educational interventions designed to increase coverage of three vaccines recommended during adolescence among Georgia middle and high school students (tetanus diphtheria pertussis [Tdap], meningococcal [MenACWY], and human papillomavirus [HPV] vaccines).

METHODS

We randomized 11 middle and high schools in one school district into one of three arms: (1) control; (2) educational intervention for parents only (P only); and (3) multicomponent educational intervention for parents and adolescents (P + A), which consisted of educational brochures for parents about vaccines recommended during adolescence and a vaccine-focused curriculum delivered to adolescents by science teachers. We obtained vaccination coverage data during intervention years from the state immunization registry.

RESULTS

Odds of receiving at least one vaccine during the study were higher among adolescents in P + A arm compared to control (Odds Ratio [OR]: 1.4; 95% Confidence Interval [CI]: 1.1-2.0). Adolescents in P + A arm had greater odds of receiving at least one vaccine compared with those in P only arm (OR: 1.4; 95% CI: 1.1-1.7).

CONCLUSIONS

A multicomponent educational intervention for adolescents and parents increased adolescent vaccination uptake. Results suggest similar interventions can increase awareness and demand for vaccines among parents and adolescents.

Parents' Experience and Views of Vaccinating Their Child against Influenza at Primary School and at the General Practice

The purpose of this study was to gain an in-depth understanding of parents’ experience and views of vaccinating their four to six-year-old child against influenza at school and at the general practice (GP). A cross-sectional qualitative study was conducted between March–June 2016 with parents of children in Reception and Year 1 in four randomly selected schools in Bury, Leicestershire, and Surrey, England. Twenty-five outreach forms were completed and returned, and seven interviews were conducted. Interview transcripts were coded by theme in NVivo (version 11, QSR International Pty Ltd., Melbourne, Australia). The primary reason parents gave for vaccinating their child was to prevent their child from contracting influenza. Parents’ perceived benefits of vaccinating in schools were to avoid the inconvenience of having to take their child to the GP, and that their child would behave better at school. Parents viewed that accompanying their child for the vaccination at school would undermine the convenience and peer-pressure advantages of the school as a venue. No parents expressed concern about their child being too young to be vaccinated in school. This research suggests that the school is a desirable venue for childhood influenza vaccination, both from the parents’ view and given that influenza vaccination coverage is higher when delivered through schools than GPs.

Human Papillomavirus Vaccine Sources of Information and Adolescents' Knowledge and Perceptions

Understanding where adolescents obtain information about human papillomavirus (HPV) vaccines may be helpful in designing public health interventions promoting HPV vaccination. This study assessed the following: (1) exposure to specific sources of information about HPV vaccines, (2) self-reported helpfulness of these sources of information, and (3) whether the specific source of information was associated with knowledge and perceptions about HPV vaccines among adolescent girls. There were 339 adolescent girls (mean age = 16.8 years) recruited into the study. Television advertisements, the Internet, doctors/nurses, and mothers were the most frequently reported sources of vaccine information; more than 90% of participants who received information from these sources reported they were helpful. Adolescents who received information about HPV vaccines from television advertisements, the Internet, clinicians, and mothers had higher knowledge about HPV vaccines and more positive perceptions. Assuring the accuracy of messages from these sources will be essential, given their importance in influencing adolescents' knowledge and perceptions about HPV vaccines.

Facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination in the United States: Systematic review

The study objective was to identify facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination in the United States. In 2009, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention expanded their recommendations for influenza vaccination to include school-aged children. We conducted a systematic review of studies focused on facilitators and barriers of parental attitudes toward school-located influenza vaccination in the United States from 1990 to 2016. We reviewed 11 articles by use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework. Facilitators were free/low cost vaccination; having belief in vaccine efficacy, influenza severity, and susceptibility; belief that vaccination is beneficial, important, and a social norm; perception of school setting advantages; trust; and parental presence. Barriers were cost; concerns regarding vaccine safety, efficacy, equipment sterility, and adverse effects; perception of school setting barriers; negative physician advice of contraindications; distrust in vaccines and school-located vaccination programs; and health information privacy concerns. We identified the facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination to assist in the evidence-based design and implementation of influenza vaccination programs targeted for children in the United States and to improve influenza vaccination coverage for population-wide health benefits.

Influence of Sources of Information and Parental Attitudes on Human Papillomavirus Vaccine Uptake among Adolescents

STUDY OBJECTIVE

The purpose of this study was to: 1) describe parental sources of information about human papillomavirus (HPV) vaccination for adolescents, 2) understand how parental sources of information about HPV vaccine are associated with adolescent HPV vaccine uptake, and 3) understand if the relationship between a greater number of HPV-related information sources and HPV vaccine uptake among adolescents is mediated by parental attitudes.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

We conducted a 3-arm randomized controlled trial in middle and high schools in eastern Georgia from 2011 to 2013. As part of the trial, we surveyed parents during the final year to understand their sources of information about HPV vaccine for their adolescent. Data were collected from 360 parents via phone and online surveys.

MAIN OUTCOME MEASURES

Parents responded to a survey that asked them to identify demographic information, parental HPV attitudes, sources of information about HPV vaccination, and HPV vaccine uptake.

RESULTS

Most of the sample was African American (74%; n = 267) and 53% of parents (n = 192) reported that their adolescent received at least 1 HPV vaccine dose. The top sources of information about HPV vaccine reported by parents were a doctor or medical professional (80%; n = 287) and television (64%; n = 232). A mediation analysis showed sources of information about HPV vaccine are associated with parental attitudes, and parental attitudes about HPV vaccine are associated with vaccine uptake among adolescents.

CONCLUSION

These findings highlight the importance of HPV sources of information on parental attitudes.

Influence of sources of information about influenza vaccine on parental attitudes and adolescent vaccine receipt

In 2011-2012, only 34% of 13-17 years olds in the United States (US) received seasonal influenza vaccine. Little is known about the link between parents' sources of health information, their vaccine-related attitudes, and vaccination of their adolescent against influenza. This study seeks to determine the relationship between number of sources of information on influenza vaccine, parental attitudes toward influenza vaccine, and influenza vaccine uptake in adolescents. We conducted a telephone and web-based survey among US parents of students enrolled in 6 middle and 5 high schools in Georgia. Bivariate and multivariable analyses were conducted to examine associations between the number of information sources about influenza vaccine and vaccine receipt and whether parent vaccine-related attitudes act as a mediator. The most commonly reported sources of information were: a physician/medical professional (95.0%), a family member or friend (80.6%), and television (77.2%). Parents who had higher attitude scores toward influenza vaccine were 5 times as likely to report their adolescent had ever received influenza vaccine compared to parents who had lower attitude scores (adjusted odds ratio (aOR) 5.1; 95% confidence intervals (CI) 3.1-8.4; P < 0.01). Parent vaccine-related attitudes were a significant mediator of the relationship between sources of information and vaccine receipt. In light of the low response rate and participation in an adolescent vaccination intervention, findings may not be generalizable to other populations. This study shows the importance of multiple sources of information in influencing parental decision-making about influenza vaccine for adolescents. Harnessing the power of mass media and family members and friends as health advocates for influenza vaccination can potentially help increase vaccination coverage of adolescents.

Association of School-Based Influenza Vaccination Clinics and School Absenteeism--Arkansas, 2012-2013

BACKGROUND

Influenza is a major cause of seasonal viral respiratory illness among school-aged children. Accordingly, the Arkansas Department of Health (ADH) coordinates >800 school-based influenza immunization clinics before each influenza season. We quantified the relationship between student influenza vaccination in Arkansas public schools and school absenteeism during the 2012-2013 influenza season.

METHODS

The relationship between the percent of students vaccinated in Arkansas public schools during ADH-facilitated clinics and the average daily percent of students absent from school during the 2012-2013 influenza season was quantified using linear regression modeling. The effect of increasing vaccination coverage among students on absentee days in the Arkansas public school system was estimated.

RESULTS

For every 1% higher vaccination coverage, 0.027% fewer absenteeism days were predicted. Larger school size was associated with higher absenteeism and predicted decreases in absenteeism were larger in magnitude for larger schools compared with smaller schools. Extrapolation of the model showed that a 10% higher vaccination level was associated with a reduction of 16-163 student absentee days per school over a 12-week influenza season.

CONCLUSIONS

Influenza vaccination is an effective tool to reduce school absenteeism. School-based clinics are a feasible way to target influenza vaccinations to school-aged children.

Parental perceptions of school-based influenza immunisation in Ontario, Canada: a qualitative study

OBJECTIVE

To understand the perspectives of Ontario parents regarding the advantages and disadvantages of adding influenza immunisation to the currently existing Ontario school-based immunisation programmes.

DESIGN

Descriptive qualitative study.

PARTICIPANTS

Parents of school-age children in Ontario, Canada, who were recruited using a variety of electronic strategies (social media, emails and media releases), and identified as eligible (Ontario resident, parent of one or more school-age children, able to read/write English) on the basis of a screening questionnaire. We used stratified purposeful sampling to obtain maximum variation in two groups: parents who had ever immunised at least one child against influenza or who had never done so. We conducted focus groups (teleconference or internet forum) and individual interviews to collect data. Thematic analysis was used to analyse the data.

SETTING

Ontario, Canada.

RESULTS

Of the 55 participants, 16 took part in four teleconference focus groups, 35 in 6 internet forum focus groups and four in individual interviews conducted between October 2012 and February 2013. Participants who stated that a school-based influenza immunisation programme would be worthwhile for their child valued its convenience and its potential to reduce influenza transmission without interfering with the family routine. However, most thought that for a programme to be acceptable, it would need to be well designed and voluntary, with adequate parental control and transparent communication between the key stakeholder groups of public health, schools and parents.

CONCLUSIONS

These results will benefit decision-makers in the public health and education sectors as they consider the advantages and disadvantages of immunising children in schools as part of a system-wide influenza prevention approach. Further research is needed to assess the perceptions of school board and public health stakeholders.