Integrating the CARD (Comfort Ask Relax Distract) system in a mass vaccination clinic to improve the experience of individuals during COVID-19 vaccination: a pre-post implementation study

Figures & data

Table 1. Demographic characteristics of vaccine recipients and vaccinators.

Vaccine recipients
	Before CARD implementation	After CARD implementation	p-Value
Age in years (mean, SD)
	31.6 (14.0)	38.4 (17.8)	<.001
Gender (N, %)
Male Female Other	586 (55.6) 450 (42.7) 18 (1.7)	664 (50.6) 626 (47.7) 23 (1.8)	.022
COVID-19 vaccine dose (N, %) First dose Second dose
	923 (88.8) 117 (11.3)	99 (7.5) 1222 (92.5)	<.001
Vaccinators
Age in years (N, %) 16–20 21–30 31–40 41–50 51–60	4 (9.8) 16 (39.0) 10 (24.4) 9 (22.0) 2 (4.9)
Gender (N, %) Male Female Other	32 (78.0) 8 (19.5) 1 (2.4)
Role (N, %) Physician Pharmacist Nurse Health Profession Student Security/Volunteer Other	10 (24.4) 2 (4.9) 16 (39.0) 5 (12.2) 7 (17.1) 1 (2.4)

Table 2. Estimated odds ratio with 95% confidence intervals for self-reported pain, fear, and dizziness in COVID-19 vaccine recipients.

	Odds ratio (95% confidence interval)
	Needle Pain	Needle Fear	Dizziness
After implementation of CARD	0.25 (0.15–0.41)	0.60 (0.37–0.99)	0.56 (0.43–0.74)
Gender (Male)	0.54 (0.45–0.65)	0.39 (0.32–0.47)	-
Age (Years)	0.96 (0.95–0.97)	0.97 (0.96–0.98)	0.98 (0.97–0.99)
Vaccine (Dose 2)	-	0.48 (0.32–0.73)	-
Side effects concerns	-	5.50 (3.96–7.64)	3.15 (2.17–4.56)
Needle fear concerns	-	-	1.47 (1.10–1.97)
CARD:age interaction	1.04 (1.03–1.06)	1.02 (1.00–1.04)	-

Table 3. Summary of vaccinator attitudes about vaccine recipient comfort, the clinic environment and adoption of the CARD system.

	Mean (SD)
Attitudes about vaccine recipient comfort
I believe that pain and fear during vaccination can have a negative effect on patients	4.4 (0.5)
Patients should be given information about how to make vaccinations more comfortable	4.2 (0.7)
Clinic staff should be given information about how to make vaccinations more comfortable	4.4 (0.8)
Clinic Environment
The clinic staff work together as a well-coordinated team	4.7 (0.5)
I experience good collaboration with other clinic staff and managers	4.7 (0.5)
I experience good collaboration with patients	4.5 (0.6)
I can easily speak up if I perceive a problem with patient care in my clinic	4.3 (0.8)
Disagreements in my clinic are resolved appropriately	4.3 (0.7)
It is easy for staff in my clinic to ask questions when they do not understand something	4.7 (0.5)
The levels of staffing in my clinic are sufficient to handle the number of patients	4.6 (0.5)
Meetings/huddles are regularly performed to discuss work processes in my clinic	4.6 (0.6)
I value meetings/huddles in my clinic	4.3 (0.7)
I regularly provide input during meetings/huddles in my clinic	3.7 (0.9)
My input is well received during meetings/huddles in my clinic	4.1 (0.7)
Attitudes about CARD
I am willing to try new ways to deliver vaccinations	4.3 (0.7)
I understand the individual components of the CARD system	3.9 (1.2)
The CARD system is aligned with our organizational goals for delivering vaccinations	4.2 (0.8)
I believe that the CARD system improves the patient experience during vaccinations	4 (0.9)
I believe that the CARD system reduces stress-related reactions like fear and dizziness	4.1 (1.0)
I am confident in my ability to use the CARD system to reduce pain and fear in patients	3.7 (1.1)
I am willing to try all components of the CARD system	4.1 (0.9)
I believe the CARD system is being used in my clinic	3.9 (1.0)
I believe patients should know about the CARD system before coming to the clinic	3.7 (1.1)
I have the support I need from other personnel and leads to implement the CARD system	4.0 (0.9)
I would recommend the CARD system to improve the vaccination experience	3.9 (0.9)
I think it is realistic to continue to use the CARD system in our setting	4.0 (0.9)
I am likely to continue to use the CARD system in the future	3.9 (1.0)

Agreement with items assessing using 5-point Likert scale: strongly disagree, disagree, neutral, agree, strongly agree.

Table 4. Vaccinator practices after implementation of CARD system (vs. usual practice).

	Selection (%)
Actions specific to vaccinators	Less	Same	More
Obscure needles	4.2	87.5	8.3
Have a support person present	8.0	88.0	4.0
Allow seating for support person	4.0	84.0	12.0
Provide privacy to patients	0.0	85.2	14.8
Use neutral language (e.g., say ‘vaccine’ instead of ‘shot’)	0.0	71.4	28.6
Inject patients while they are lying down	0.0	75.0	25.0
Omit alcohol swab from injection process	8.3	41.7	50.0
Inject without aspiration	3.7	96.3	0.0
Inject vaccine quickly (i.e., <2 seconds)	3.8	88.5	7.7
Counsel patients about using topical anaesthetics in the future	13.0	60.9	26.1
Actions involving vaccine recipients
Ask patients about their level of fear before injection	3.6	64.3	32.1
Ask patients about preferred coping strategies	7.4	51.9	40.7
Invite patients to ask questions before injection	0.0	64.3	35.7
Ask patients to keep arm loose and still	0.0	88.9	11.1
Ask patients about their symptoms after injection	4.0	68.0	28.0
Ask patients to use muscle tension	4.3	47.8	47.8
Ask patients to use verbal distraction (i.e., talk to you or someone else)	0.0	72.0	28.0
Ask patients to use devices as distraction items (e.g., cell phone)	0.0	64.0	36.0
Ask patients to use relaxation breathing techniques (e.g., deep breathing)	0.0	54.2	45.8