Abstract
School-located immunization programs (SLIP) will only be successful if parents consent to their children's participation. It is critical to understand parent perspectives regarding the factors that make them more or less likely to provide that consent. Organizations creating SLIPs will be able to capitalize on the aspects of SLIPs that parents appreciate, and address and correct issues that may give rise to parent concerns. This study involved five focus groups among the parents of school students in a large, urban school district. Findings highlight the broad range of concepts important to parents when considering participation in a SLIP. The safety and trust issues regarding vaccines in general that are so important to parents are also important to parents when considering participation in a SLIP. Effective communication strategies that include assurances regarding tracking of information and the competence and experience of immunizers will be helpful when addressing parents regarding SLIPs. In addition, parents were very cognizant of and positive regarding the public health benefits associated with SLIPs. Further study among larger populations of parents will further refine these ideas and aid in the development of successful influenza vaccine SLIPs that directly address and communicate with parents about the issues most important to them.
Introduction
For the 2010–2011 influenza season, the Advisory Committee on Immunization Practices (ACIP) recommended the universal vaccination of all persons age 6 months and older with the influenza vaccine.Citation1 This recommendation built upon a prior universal recommendation that expanded the recommendation among children to all those 6 mo of age through 18 yCitation1 With these recommendations comes the challenge of accessing adolescent patients who are historically difficult to reach for preventive care; for example, it is estimated that only 9% of adolescents age 11–21 y of age accessed the health care system for comprehensive preventive care between the years of 1994 and 2003.Citation2
Research indicates that the additional burden of annual influenza vaccination, assuming patient adherence, has the potential to overwhelm primary care practices.Citation3 Alternative immunization sites will be needed to deliver these vaccines each year. School-located immunization programs (SLIPs) hold the potential to reach many adolescents at the place, where they spend a significant amount of time. SLIPs for influenza vaccine have been successful in the past few years in Maryland,Citation4 Tennessee,Citation5 and West VirginiaCitation6 with nearly 50% of students being immunized. Cost effectiveness analysis indicates that SLIPs are also potentially cost-effective ways of reaching youth for immunization.Citation7
Studies exploring parental willingness to have their children immunized via SLIP have shown that many parents report willingness to utilize such a program.Citation8-Citation11 In fact, among all vaccine choices, parents report feeling most comfortable with their children receiving the influenza vaccine via SLIP.Citation11 Schools also benefit from influenza vaccine SLIPs; immunizing large proportions of the student body against influenza using SLIPs has been shown to reduce absenteeism during the influenza season.Citation12 Few studies, however, have examined what specific factors associated with SLIPs would make parents more or less likely to consent to their child’s participation.
The research aim for this study was to determine directly from the parents of school-aged children what they report as important factors associated with SLIPs that would make them more or less likely to agree to their child’s participation.
Results
Focus group participants
–Five focus groups consisting of 6–9 adults (n = 37 parent/guardians) were conducted. Thirty-two (87%) of the parent/guardians were female, 27 of whom were mothers. Sixteen (43%) were black-not Hispanic, 7 (19%) were white-not Hispanic, and the remainder were Hispanic. Fifteen (41%) reported having Medicaid/CHIP; 31 (84%) had a college degree or higher. Parent/guardian ages ranged from 33–58 y.
Engagement questions
All but one parent reported having heard of the flu, and all parents reported having heard about the flu vaccine. Twenty-four parents (65%) reported having received the vaccine in the past and 22 (60%) reported that their child had received the vaccine. Ten parents (27%) reported their child had been part of a school-located program.
Knowledge about the flu and the flu vaccine was basic yet mostly accurate, as indicated by one parent who said, “It is a virus. Um, little bit more severe than a cold.” Parents also described various symptoms and levels of severity of the flu. Interestingly, the idea of contagion was of great concern, and multiple parents in groups remarked on how contagious the virus is. When describing the vaccine, parents seemed very concerned about the efficacy and safety of the vaccine, as well as the indications for getting the vaccine. For example, one parent stated, “It [the flu] is unstable, so it’s changing constantly. There are different types so you can be vaccinated for one type and not necessarily cover all the other types.” With regard to indications for getting the vaccine, one parent stated, “I know it’s—if you, um—most of them recommend it if you have any type of respiratory problems…. Well, anybody if you really want it, but mostly those younger age, respiratory problem, the elderly, um, that’s recommended more for them.” While most parents report accurate information about the vaccine, some parents were inaccurate about some aspects of the vaccine. For example, one parent stated, “I was told, but I don’t know if it is a fact, that it actually gives you the flu.” Another parent said, “I think it can be a plus for some people and maybe harmful to others. It just depends, um, your situation I would say. Each person – it’s individualized.”
Exploratory questions
As stated above, there were four exploratory questions, and all questions were conducted with the groups using nominal group method.
Benefits of getting vaccinated at school
Groups described many benefits of getting vaccinated at school, and there were several benefits that were brought up in every group (convenience, cost, knowing their child will be vaccinated). provides a list of benefits and the sum of their rankings.
Table 2. List of responses and their rankings by school to the question, “What are the benefits to getting children vaccinated in the school?”
Other benefits that were listed by parents in more than one group included parents not having to miss work, knowing all/more kids are vaccinated, and the benefit of decreased sick days for the child.
Also not listed in were those benefits that were brought up only in one group. Many of these benefits seemed specific to one or two individuals (i.e., my child will act better because others are watching, I know my child will get the right vaccine or the most current vaccine). It also should be noted that one parent ranked the following item in her top five ranking of benefits: “Prevent schools from closing due to a flu epidemic.” One parent went further and stated, “…but every adult at school should have the vaccine…That way, everyone in the whole community has had the vaccine.”
Drawbacks of getting vaccinated at school
Groups listed several perceived drawbacks of getting vaccinated at school and the responses ranked most often by parents in the groups are listed in .
Table 3. List of responses and their rankings by school to the question, “What are the drawbacks to getting children vaccinated in the school?”
Other drawbacks reported by more than one group included: not knowing who will be giving the vaccine/less control over those giving it, chances of contamination/unsanitary conditions, not knowing the lot number of shots/where the shot comes from, getting information/consent to and from parents, authenticating parent signature/liability for the school, and managing those kids whose parents don’t want them to get the vaccine.
What would make parent more likely to use a SLIPS
Groups were able to give several features of SLIPs that would make them more likely to use such a program for their child’s vaccines. The top-ranked reasons are listed in .
Table 4. List of responses and their rankings by school to the question, “What would make you more likely to get your child vaccinated at school?”
Other items reported by more than one group included: knowing the SLIP’s schedule beforehand and/or having the opportunity to ask questions, less time away from work or school, and knowing your child will be vaccinated (not affected by shortages), having a choice to participate, and being able to protect the health of your child.
Less important items described by only one group included: the desire to volunteer on vaccine day, the importance of organic ingredients, concern about hygienic conditions at school, not having to go to a public clinic, the assurance of enough vaccine for each child, assurance of contact in case “something happens,” wanting to know if extra personnel are available to help (vitals), being advised of medical practitioners who were administering vaccine, having students be given incentives, if the vaccine is required by law (in fact, one parent said, “Or if it is mandatory, I’m not gonna do it.”), if the vaccine is medically necessary, and being given the right information about the school-located program.
What would make a parent less likely to use a SLIP
The most commonly ranked reasons identified by parents as making it less likely they would have their child participate in a SLIP are listed in .
Table 5. List of responses and their rankings by school to the question, “What would make you less likely to get your child vaccinated at school?”
Other variables mentioned by more than one group to be associated with parents being less likely to get the vaccine included lost school time include concerns regarding: disorganization in the schools (schedule, who receives vaccine, paperwork), more errors can happen at school (giving vaccine, paper work errors), if the parents did not know which hospital/doctor was administering vaccine, if parents can’t be there with their child, if the child is scared, if there was a cost or fee, feeling that the child’s physician know their child better, and the feeling that there may be no need to get the vaccine or having been advised not to get the vaccine.
Items noted by only one group as making it less likely to participate in a SLIP included: if it was mandatory, if it were before or after school because lines will be long, long wait times for vaccination, if there were no contact person, not having right medical information at school, the potential for embarrassment in front of peers, not enough staff, if the child had special needs, if something medical/outbreak were going on at school, if the school needed to use force/restraint to vaccinate a child, if the school were not available to ask questions, if the parent were being “pressured” by school, timeframe for vaccination is greater than a week, not knowing when shots were going to be given, not knowing if their child were being given the correct dosage/medicine, if the child had already been vaccinated, if consent were not required, if the parent didn’t like the person administering vaccine, distrust of public systems, not being notified in a timely manner of a reaction, not wanting the child to get the vaccine.
No major differences in responses were observed between groups from elementary, middle, and high schools.
Exit questions
When asked if the delivery method (injection vs. intranasal) might influence their decision regarding SLIP participation, 23 (62%) parents indicated that it would. If the vaccine were other than the flu vaccine, 20 (54%) parents indicated that their thinking about participation would be different.
When asked about measures to ensure that consent gets home and signed, parents had several ideas. Most of these ideas centered around two main concepts, including improved communication with the parents and incentives for students (and parents) to return the consents. With regard to communication, parents suggested various modes of communication including email, calling and using already in place technology (i.e., gradebook). One parent expanded on this concept saying, “Considering that we’re in an age of technology, I would like to see it done in either email or they have the new gradebook where parents go into them. Maybe have an attachment where they sign in there to give us the permission.” Another parent felt that multiple modes of communication may be helpful, “I think you have to use multiple means. You have to mail it, hand it out to the kids, and send it via email.” Last, some parents suggested communication means that did not involve technology. One parent stated, “Like town hall—to inform the public.” Another parent suggested, “Make it part of the enrollment packet….Start early on so that when people enroll their children, primarily the parent is the one enrolling the child, it can be given during the school year. It should be signed and information given to the parent at that time….If the nurse is there, they can ask the nurse all the questions. They would like to ask at that time, you know.”
In terms of incentives, parents had a variety of ideas regarding incentives for their child, including activities, tangible items, and food. For example, one parent stated, “I think there should be some type of incentive for the kids like a fair, you know, not a big to-do thing, but something, some type of activity or something.” Another parent suggested, “Free dress or free pizza coupon or something to ensure that it gets done the right way.” Even though most parents believed incentives should be provided to the children, other parents felt incentives also should be provided to parents, “I think there would have to be incentives at the parent level. You could offer them (kids) candy and they’ll be thrilled. They’ll take an HIV test. They’ll do anything. But there has to be really good incentives for parents, but more than that, there has to be a great distribution of information.”
Finally, in response to adding any additional thoughts, most responses focused on wanting the programs to allow parents to be present for the immunization. One parent stated that she wanted to come with her child, “You know if your baby is going to act like a monkey, you know what I’m saying. Gonna be beating up the doctor and the nurses. Come with them. You know, on a Saturday, when you are off from work. Ok, it’s convenient to go to the school. You don’t have to miss no day at work and be right there with them.” Another wanted to come, but worried about availability of time. “But they have to give parents several days because I know, if you give it on Monday, no one’s gonna remember. So, if you have several days, then you’ll have more participation.”
Parents also were concerned about vaccine safety in general. Several parents mentioned fear of needles, fear of autism resulting from vaccines, and feeling uncomfortable with the liability the school would be taking on with vaccination. One person stated, “I want to see you draw up that vaccination. It is just too much that can go wrong….and a simple sorry is not going to suffice. You can’t say sorry for injuring my child. I’m sorry.”
Discussion
The parents of students in a large, urban school district are generally knowledgeable about influenza and influenza vaccine and have a broad base of thinking about SLIPs for influenza vaccination. Despite some issues of concern, they seem to appreciate a wide breath of benefits associated with SLIPS. Parent responses regarding factors that would make them more or less willing to have a child participate in such programs range between those pertaining to personal safety to personal convenience to the public health benefits associated with herd immunity. Themes that seem particularly important to parents include issues related to trust. This is not surprising given the concern parents have regarding the trust in vaccine safety in general.Citation13,Citation14 Safety issues were expressed primarily when parents responded to the question regarding items that would make a parent less likely to have their child vaccinated at school; parents ranked “side effects” and “safety issues.” Trust concerns were expressed as “knowing or trusting the person administering the vaccine” and “knowing a competent person (i.e., nurse or doctor) is administering the vaccine.” The worries that parents voiced about whether the program used clean/sterile equipment are consistent with issues of trust in the program as well. Safety and trust in the competency of the program were common themes in all of the groups.
Interestingly, parents were very supportive of all of the public health benefits of the SLIP itself, specifically that there would be enough vaccine for the entire school and that the whole school would be protected against the flu. Parents are aware of the concept of herd immunity—the idea that this diminished risk of contagion, in turn, will provide better protection to each child. The importance of decreased cost and increased convenience of school vaccination also were consistently noted as important across groups; these findings along with focus group concerns about parental desire to be with children for vaccination and concerns regarding competent vaccinators were also previously reported by Allison, et al.Citation15 Also noted previously in the literature,Citation10 having the school have access to the vaccination record was viewed favorably by parents. Parental awareness and emphasis of the public health benefits of SLIPS and the importance these benefits play in their SLIP participation decision-making are unique findings not previously emphasized in the literature.
The potential influence of friends was of varying importance to parents. Some parents felt that having friends present for vaccination would help support their children; others were concerned that it would be a deterrent for the youth and potentially cause embarrassment. Incentives and rewards for vaccination itself, while mentioned, were not ranked as particularly important among parents; the other pros and cons associated with SLIPs were more pressing.
Most parents (62%) reported that delivery method of the vaccine (intranasal vs. injection) would influence their participation in the SLIP. This likely results from an understanding of children’s preferences for intranasal influenza vaccine over delivery via injection.Citation16,Citation17 Delivery method has an effect on parent participation, but it may have an effect on the efficiency of SLIPs as well. Time motion studies indicate that administration time for the intranasal product is no more than and may be somewhat shorter per individual vaccination given than the influenza vaccine injection, potentially improving the cost-effectiveness of influenza SLIPs as well.Citation18
In general, parents felt that incentives would help with the return of consent forms. Interestingly, some comments were made suggesting incentives for the parents, as well as for the children. Because all groups noted the improved convenience and low/no cost of the SLIP, it will require further investigation to determine if this might serve as enough incentive for the parents to return the immunization consent forms. The cost of SLIPs, in general, is always a potential obstacle for program implementation; the potential for programs to bill third party payors as appropriate is one strategy that can help parents avoid all cost concerns.
The limitations of this research are the ones inherent in focus group research. It is not clear that the issues of concern to this relatively highly educated population of parents from one geographic area are generalizable to the population in general. In addition, there may be selection bias in groups with parents who are willing or have time to attend focus group discussions. However, these discussions are revealing in the relatively rapid saturation of concerns achieved after five groups, indicated that the themes described are common among parents within this school district.
School-located immunization programs will only be successful if parents consent to their children’s participation. It is critical to understand parent perspectives regarding the factors that make them more or less likely to provide that consent. Those creating SLIPs will be able to capitalize on the aspects of SLIPs that parents appreciate, and address and correct issues that may give rise to parent concerns. This study highlights the broad range of concepts important to parents when considering participation in a SLIP. The safety and trust issues regarding vaccines in general that are so important to parents carry over to their concerns about SLIPs. Effective communication strategies that include assurances regarding tracking of information and the competence and experience of immunizers and immunizing programs will be helpful when addressing parents regarding SLIPs. In addition, emphasis of the public health benefits associated with SLIPs could potentially increase program participation as well. Further study among larger populations of parents will further refine these ideas and aid in the development of successful influenza vaccine SLIPs that directly address and communicate with parents about the issues most important to them. Implementing strategies that address known concerns of families will help school-located immunization programs reach a much greater number of all youth, including traditionally underserved youth, in the environment in which they spend the most time – schools.
Methods
This study was conducted using focus groups.
Recruitment
Parents from one elementary, two middle, and three high schools in a large urban school district in Houston were recruited for participation. Fliers were posted in the chosen schools and/or were sent home. Parents were instructed to call the research phone line for any additional information regarding the study and to confirm their participation. If at least 6 participants had not confirmed participation for each group, school nurses called parents who they felt might contribute to the group, and offered participation. Parents/guardians who did not speak English were excluded from participation in the study.
Focus groups
In May, 2010, focus groups consisting of 6–9 participants were conducted at their home school. One parent group consisted of parents from two different, yet nearby high schools. Groups were up to 90 min in duration and were conducted after school hours. Food was provided for participants and each participant was reimbursed $30 for his/her time. Each group was facilitated by a master’s level graduate student in clinical psychology. Questions were developed by the authors based on existing literature. All focus groups were conducted in English. Focus groups were conducted until saturation (no unique responses) was achieved in group responses.
Demographic data were collected using a brief form distributed prior to the start of the focus group. Two types of qualitative methods were used during the focus groups. Open-ended forum was used for the group engagement and exit questions (). After the engagement questions were asked, an introduction was provided to the participants that included information about the recommendations from the Centers for Disease Control and Prevention (CDC). Participants were educated about the new universal annual influenza vaccination recommendation for all those 6 mo of age and older, and the two primary delivery modalities for the vaccine—intranasal and injection—were described.
Table 1. Engagement, Exploratory, and Exit Questions Used for Parent Focus Groups
Nominal group method was used for the exploratory questions for the groups (). Attitudes and perceptions regarding what factors are important to parents when considering use of a SLIP were ranked by the group. The nominal group method was chosen to help establish consensus among the groups; it is a method commonly used in health and medicine with the aim of rapidly producing decisions.Citation19 For the exploratory questions, participants were asked to list answers to each question on a piece of paper. Each participant provided their answers to the facilitator while a research assistant wrote them on a computer screen projected for the group. Once all responses were recorded, group discussion ensued to clarify and rephrase, then amalgamate responses and remove any duplicate items. The final list was presented on the screen and participants were asked to rank their top five priority items from the list in order of perceived importance. These rankings were turned in to the facilitator.
Each group was audiotaped and was later transcribed. All recruitment and study procedures were approved by the Baylor College of Medicine and Houston Independent School District (HISD). Refreshments were provided during the focus groups, and all participants were reimbursed for their time.
Analysis
Each group transcript was read by all three authors. Yes/No responses were recorded and tallied.
Each question was analyzed separately, and rankings for each question were developed. To determine the group rankings of the factors listed as important to parents within groups, each participant’s rankings were assigned points. The item ranked as most important (the first item on the participant’s list) was assigned a point value of five, the second was assigned a four, the third a three, the fourth a two, and the fifth most important item on the participant’s list was assigned a value of one. For each group, the final list of items within each exploratory question was ranked in order according to the items that received the most points (the top ranked items) to those that received the least points.
To develop rankings across groups, response items from different groups were considered equivalent if all three authors agreed they conveyed the same meaning. To determine the final rankings across groups, the same process described above for ranking within groups was utilized.
Transcripts were read for any additional information that was not captured by the ranked lists. Information that was not previously captured was then coded into themes and noted.
For open-ended items, framework analysis was used as the structure for analyzing the data. New themes and coding were developed as the data were mapped into existing literature. The codes were reviewed for accuracy by all three authors.
Acknowledgment
This project was funded by MedImmune and, in part, by Project #1 T71 MC00022–01 from the Maternal Child Health Bureau (Title V, social Security Act), Health Resources and Services Administration, Department of Health and Human Services. Neither organization providing financial support had any role in study design; data collection, analysis and interpretation; writing of the manuscript; and decision to submit the article for publication.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
References
- Center for Diseases Control and Prevention. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2010; 59:1 - 5; PMID: 20075837
- Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med 2007; 161:252 - 9; http://dx.doi.org/10.1001/archpedi.161.3.252; PMID: 17339506
- Rand CM, Szilagyi PG, Yoo BK, Auinger P, Albertin C, Coleman MS. Additional visit burden for universal influenza vaccination of US school-aged children and adolescents. Arch Pediatr Adolesc Med 2008; 162:1048 - 55; http://dx.doi.org/10.1001/archpedi.162.11.1048; PMID: 18981353
- King JC Jr., Stoddard JJ, Gaglani MJ, Moore KA, Magder L, McClure E, et al. Effectiveness of school-based influenza vaccination. N Engl J Med 2006; 355:2523 - 32; http://dx.doi.org/10.1056/NEJMoa055414; PMID: 17167135
- Carpenter L, Lott J, Lawson B, et al. Mass Distribution of free, intranasally administered influenza vaccine in a public school system. Pediatr 2007; 120:e3172 - 178; http://dx.doi.org/10.1542/peds.2006-2603
- Gupta R. Enhancing community partnerships during a public health emergency: the school-located vaccination clinics model in Kanawha County, WV during the 2009 influenza A (H1N1) pandemic. W V Med J 2011; 107:28 - 34; PMID: 22235709
- Cawley J, Hull HF, Rousculp MD. Strategies for implementing school-located influenza vaccination of children: a systematic literature review. J Sch Health 2010; 80:167 - 75; http://dx.doi.org/10.1111/j.1746-1561.2009.00482.x; PMID: 20433642
- Clevenger LM, Pyrzanowski J, Curtis CR, Bull S, Crane LA, Barrow JC, et al. Parents’ acceptance of adolescent immunizations outside of the traditional medical home. J Adolesc Health 2011; 49:133 - 40; http://dx.doi.org/10.1016/j.jadohealth.2011.04.012; PMID: 21783044
- Middleman AB, Guajardo AD, Sunwoo E, Sansaricq KM. Parent knowledge and attitudes about school-based hepatitis B immunization programs. J Sch Health 2002; 72:348 - 51; http://dx.doi.org/10.1111/j.1746-1561.2002.tb07923.x; PMID: 12389377
- Middleman AB, Tung JS. At what sites are parents willing to have their 11 through 14-year-old adolescents immunized?. Vaccine 2010; 28:2674 - 8; http://dx.doi.org/10.1016/j.vaccine.2010.01.006; PMID: 20085835
- Middleman AB, Tung JS. Urban middle school parent perspectives: the vaccines they are willing to have their children receive using school-based immunization programs. J Adolesc Health 2010; 47:249 - 53; http://dx.doi.org/10.1016/j.jadohealth.2010.01.009; PMID: 20708563
- Hull HF, Ambrose CS. The impact of school-located influenza vaccination programs on student absenteeism: a review of the U.S. literature. J Sch Nurs 2011; 27:34 - 42; http://dx.doi.org/10.1177/1059840510389182; PMID: 21078842
- Gust D, Weber D, Weintraub E, Kennedy A, Soud F, Burns A. Physicians who do and do not recommend children get all vaccinations. J Health Commun 2008; 13:573 - 82; http://dx.doi.org/10.1080/10810730802281726; PMID: 18726813
- Shui IM, Weintraub ES, Gust DA. Parents concerned about vaccine safety: Differences in race/ethnicity and attitudes. Am J Prev Med 2006; 31:244 - 51; http://dx.doi.org/10.1016/j.amepre.2006.04.006; PMID: 16905036
- Allison MA, Reyes M, Young P, Calame L, Sheng X, Weng HY, et al. Parental attitudes about influenza immunization and school-based immunization for school-aged children. Pediatr Infect Dis J 2010; 29:751 - 5; http://dx.doi.org/10.1097/INF.0b013e3181d8562c; PMID: 20308935
- Flood EM, Block SL, Hall MC, Rousculp MD, Divino VM, Toback SL, et al. Children’s perceptions of influenza illness and preferences for influenza vaccine. J Pediatr Health Care 2011; 25:171 - 9; http://dx.doi.org/10.1016/j.pedhc.2010.04.007; PMID: 21514492
- Flood EM, Ryan KJ, Rousculp MD, Beusterien KM, Block SL, Hall MC, et al. A survey of children’s preferences for influenza vaccine attributes. Vaccine 2011; 29:4334 - 40; http://dx.doi.org/10.1016/j.vaccine.2011.04.018; PMID: 21510993
- Washington ML, Humiston SG, Fauerbach PB, Glezen WP, Black S, Shinefield H, et al. A personnel time-motion study of intranasal influenza vaccination in healthy children. Vaccine 2005; 23:4879 - 85; http://dx.doi.org/10.1016/j.vaccine.2005.05.006; PMID: 16005551
- Moore C. Nominal Group Technique. In: Group Techniques for Idea Building Chapter 2. Newbury Park, CA: Sage Publications 1987.