In Their Own Words: Resources Needed by School Nurses to Facilitate Student Immunization Compliance

Improving Vaccination Compliance Through a School-Located Vaccination Clinic

School nurses continue to focus on vaccine compliance and strategies to overcome increased hesitancy after the COVID-19 pandemic. The Santa Fe Public Schools district (SFPS) in New Mexico offers a school-located vaccination clinic (SLVC) through the Vaccines for Children Program (VFC). The SFPS SLVC provided the student population 2,524 vaccines from 2023-2025 and will continue to provide more vaccines through the rest of the 2024-2025 school year and beyond. This article will outline the SFPS SLVC operations, challenges, and recommendations for other districts considering implementing an SLVC. Barriers to vaccine compliance and mitigation strategies including communication enhancements, incentivization, and the role of social media will also be discussed.

Perspectives of Parents, School Nurses, and Pediatricians on Vaccine Hesitancy in St Louis County, Missouri

OBJECTIVES

To gather perspectives on childhood vaccination and vaccine hesitancy, the Saint Louis County Department of Public Health (DPH) surveyed parents seeking nonmedical exemptions, conducted focus groups of school nurses, and interviewed pediatricians.

METHODS

We distributed exemption forms and voluntary questionnaires to parents in St Louis County who were seeking nonmedical exemptions for their school-aged children at any DPH clinic from August 2019 through December 2022. We conducted and recorded four 75- to 90-minute focus groups of 11 school nurses in groups of 2 or 3 nurses in September 2022. We conducted and recorded interviews of 8 pediatricians in March 2023. We calculated descriptive statistics, transcribed focus group discussions and interviews, and performed qualitative coding.

RESULTS

We collected 1871 exemption forms. The median age of children (n = 1854) was 6 years. Of the 10 vaccines included in the exemption list, the percentage of exclusions ranged from 91.2% for meningococcal conjugate to 88.7% for hepatitis A. We identified 4 themes in the focus groups: recent changes in vaccine compliance, hesitancy and barriers, services addressing hesitancy and barriers, and future requests for DPH. Analysis of pediatrician interviews revealed themes relating to vaccine information, community efforts, and physician decision-making.

CONCLUSIONS

This study highlights the need for a multidisciplinary approach to vaccine hesitancy in St Louis County. Future interventions need to focus on beliefs and behavioral change related to vaccines and not just the economics and accessibility of vaccines.

HPV Vaccination Rates of 7th Grade Students After a Strong Recommending Statement from the School Nurse

The Human Papillomavirus (HPV) vaccine can prevent 90% of cancers caused by HPV. Health care provider recommendations affect vaccine uptake, yet there are a lack of studies examining the impact of the school nurse (SN) in vaccine recommendations. The purpose of this study was to evaluate the impact of adding a SN HPV recommendation to the standard vaccination letter sent to parents/guardians. The rate of vaccination between the intervention and control schools was not statistically significant (Estimate (Std. Error) = -0.3066 (0.2151), p = 0.154). After controlling for age, sex, race, insurance type, and medical practice type, there was no significant difference in the likelihood to receive the HPV vaccine (OR = 1.53, 95% CI: 0.563-4.19 in 2018; OR = 1.34, 95% CI: 0.124-14.54 in 2019. Further work is needed to clarify how school nurses can better promote HPV vaccine, and which adolescent demographic groups (e.g., race, insurance type, provider type) face barriers to HPV vaccine uptake.

Impact of the COVID-19 Pandemic on Pennsylvania School Nurse Management of Student Immunization Requirements

School nurses play a significant role in the coordination of school-entry immunization requirements across the United States. The COVID-19 pandemic changed the school landscape and introduced additional responsibilities to a school nurse's workload. We conducted a cross-sectional survey with n = 110 Pennsylvania school nurses to explore the impact of the COVID-19 pandemic on school-entry immunization compliance management. Qualitative and quantitative data indicated increased difficulty obtaining school-entry immunization data (n = 52) and reduced school-level enforcement of immunization compliance (n = 30). We also observed increases in the percentage of students enrolled with an immunization exemption in Kindergarten, 7th, and 12th grades between the 2019-2020 and 2020-2021 school years. However, few respondents (15%) offered school-located immunization clinics (SLIC) for school-entry-required immunizations. While the benefits of SLICs are documented, the capacity required to execute recommended actions may be limited among school nurses-particularly post-COVID-19 pandemic. School nurses may need additional support to address these gaps.

Exploring the impact of the New York State repeal of nonmedical vaccination exemptions on student enrollment, absenteeism, and school workload: Perspectives from a survey of school administrators

In June 2019, New York State (NYS) adopted Senate Bill 2994A eliminating nonmedical vaccine exemptions from school entry laws. Since student noncompliance with the law required school exclusion, we sought to evaluate the law's effects on student enrollment and absenteeism, and school workloads related to its implementation. In November 2019, we sent an electronic survey to NYS (excluding New York City) schools. Due to the COVID-19 pandemic, outreach was curtailed in March 2020 with 525 (14%) of 3,759 eligible schools responding. To account for non-response, results were analyzed using inverse probability weighting. After weighting, 39% (95% CI: 34%, 44%) of schools reported enrollment changes and 31% (95% CI: 26%, 36%) of schools reported absenteeism related to the law. In addition, 95% (95% CI: 93%, 98%) of schools reported holding meetings and/or preparing correspondence about the law, spending a mean of 14 (95% CI: 11, 18) hours on these communication efforts. Schools in the highest pre-mandate nonmedical exemption tertile (vs. lowest) were more likely to report enrollment and absenteeism changes, and higher workloads. While our results should be interpreted with caution, changes in student enrollment, absenteeism, and school workloads may represent important considerations for policymakers planning similar legislation.

Addressing Vaccine Hesitancy Among Students and Families: Interventions for School Nurses

Vaccine hesitance is a public health issue that school nurses often address in practice. It has become even more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. Vaccine compliance among schoolchildren is essential to the health of an entire community, given that many pediatric illnesses are vaccine-preventable. School nurses are involved in the promotion of vaccines in a school district, as they provide health education to students and families and are responsible for vaccine surveillance. Promoting vaccine compliance as a matter of public health can be challenging for school nurses, especially if a community holds strong beliefs regarding the necessity of pediatric vaccines. This article reviews the history of vaccine mandates, addresses challenges associated with vaccine compliance, and provides interventions school nurses can use when providing care to students and families regarding vaccine hesitancy. In following the nursing process, a school nurse is able to identify students missing vaccine(s) and evaluate for hesitancy, before implementing interventions that provide education to students and families. Several cost-efficient and accessible interventions can facilitate effective education and promote vaccine compliance. School nurses can forge trusting relationships and engage in compassionate dialogue to support vaccine compliance in the school.

The Healthy, Immunized Communities Study: A pilot intervention to increase parents' intentions to get vaccines for their middle school children

Pennsylvania shortened the provisional period for student vaccine compliance in 2018. We pilot tested a school-based health education intervention, The Healthy, Immunized Communities Study, to improve parents' intentions to get school-required (tetanus, diphtheria, acellular pertussis [Tdap]; and meningococcal conjugate [MCV]) and recommended (human papillomavirus [HPV]) vaccines for their children. In Phase 1, we partnered with the School District of Lancaster (SDL) to conduct four focus groups with stakeholders (local clinicians, school staff, school nurses, and parents) to inform the development of the intervention. In Phase 2, we randomized four middle schools in SDL to either the intervention (six email communications and school-community educational event) or control group. Seventy-eight parents took part in the intervention and 70 joined the control group. Vaccine intentions were compared within and between groups from baseline to 6-month follow-up with generalized estimating equations (GEE) models. Compared to the control, the intervention did not increase parents' vaccine intentions for Tdap (RR = 1.18; 95 % CI:0.98-1.41), MCV (RR = 1.10; 95 % CI:0.89-1.35), or HPV (RR = 0.96; 95 % CI:0.86-1.07). Among intervention participants, only 37 % opened ≥ 3 email communications and 23 % attended the event. Intervention participants reported high satisfaction with email communications (e.g., informative = 71 %) and felt that the school-community event met their educational objectives on key topics (e.g., immune system = 89 %). In conclusion, although we observed no intervention effect, our data suggest that this could be a result of the low uptake of intervention components. Further research is needed to understand how school-based vaccination-focused interventions can be successfully implemented with high fidelity among parents.

Barriers in the School-Based Pan-Gender HPV Vaccination Program in Sweden: Healthcare Providers' Perspective

BACKGROUND

Human papillomavirus (HPV) vaccines effectively prevent, and can even eliminate, HPV-related cancers. Currently, vaccination rates are suboptimal in the national Swedish school-based vaccination program. School nurses play a key role in all aspects of the vaccination process. Therefore, this study aims to explore school nurses' perceived HPV vaccination challenges.

METHODS

Seven focus group interviews were conducted with school nurses (n = 35) working in nine socio-demographically diverse municipalities in mid-Sweden. Data were analyzed using qualitative content analysis.

RESULTS

Participants described difficulties in encountering and handling the diversity of reasons for vaccine hesitancy. Parents known to be skeptical of vaccines in general were seen as most difficult to reach. Uncertainty was expressed concerning the extent of professional responsibility for vaccine promotion. The informants expressed a lack of guidelines for vaccine promotion and described challenges in supporting the child's own wishes. Creating a safe space for the individual child was seen as crucial. Other problems described were the challenges of overcoming children's fear of needles, supporting unvaccinated children, and being confronted with the remaining gender inequities of the pan-gender vaccination program.

CONCLUSIONS

Our results suggest that school nurses, especially those new to their profession, may benefit from training and guidance22 material on how to address vaccine hesitancy.