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. 2023 Apr 17;41(22):3436–3445. doi: 10.1016/j.vaccine.2023.04.032

A tailored COVID-19 vaccination pathway for children 5–11 years in Victoria, Australia

SF Gordon a,b,⁎, J Lam a, JT Vasquez a, R Cercone a, N Tenneti a, J Hart a, M Chisholm a, M Heland a, M Hoq b,c, J Kaufman b,c, M Danchin a,b,c,d
PMCID: PMC10106821  PMID: 37120401

Abstract

Background

Procedural anxiety was anticipated in children 5–11 years during the COVID-19 vaccine rollout in Victoria, Australia, as children in this age group receive few routine vaccines. Therefore, the Victorian state government designed a tailored, child-friendly vaccine program. This study aimed to assess parental satisfaction with elements of the bespoke vaccination pathway.

Methods

The Victorian government and state-run vaccination hubs in Victoria facilitated an online immunisation plan to help parents identify their child’s support needs, and utilised experienced paediatric staff and additional supports for children with severe needle distress and/or disability. All parents/guardians of children 5–11 years who received a COVID-19 vaccine in a vaccination hub were sent a 16-item feedback survey via text message.

Results

Between 9 February and 31 May 2022 there were 9203 responses; 865 children (9.4%) had a first language other than English, 499 (5.4%) had a disability or special needs, and 142 (1.5%) were Aboriginal or Torres Strait Islander. Most parents (94.4%; 8687/9203) rated their satisfaction with the program as very good or excellent. The immunisation plan was used by 13.5% (1244/9203) of respondents, with usage more common for Aboriginal or Torres Strait Islander children (26.1%; 23/88) or families with a first language other than English (23.5%; 42/179). The child-friendly staff (88.5%, 255/288) and themed environment (66.3%, 191/288) were the most valued measures for vaccination. Additional support measures were required by 1.6% (150/9203) of children in the general population and 7.9%, (17/261) of children with a disability and/or special needs.

Conclusion

A tailored COVID-19 vaccination program for children 5–11 years, with additional support for children with severe needle distress and/or disability, had high parental satisfaction. This model could be utilised for COVID-19 vaccination in pre-school children and for routine childhood vaccination programs to provide optimal support to children and their families.

Keywords: COVID-19 vaccines, Vaccination pathways, Paediatrics, Needle anxiety, Vaccine uptake

1. Introduction

In Australia, the National Immunisation Program (NIP), funded by the Australian government, aims to provide protection against vaccine preventable diseases for eligible individuals across the lifespan [1]. However, few vaccines are given routinely to children 5–11 years, with the last NIP vaccine given at 4 years against diphtheria, tetanus, pertussis and polio (DTP-IPV), followed by Human Papilloma Virus (HPV) and DTP at 12–13 years [2]. Apart from special risk or travel vaccines, the seasonal influenza vaccine is the only recommended but not funded vaccine that primary school children 5–11 years may receive. Uptake of influenza vaccine in this age group remains low (29.7% in children 5 to <10 years compared to 45.2% in children 6 months to <5 years in 2020), especially for children with no medical comorbidities [3], [4]. In addition, several local and international studies had suggested that many parents of children 5–11 years were reluctant to have their child vaccinated against COVID-19 [5], [6], [7], [8], [9], [10], [11]. Therefore, a mass COVID-19 vaccination rollout in this age group posed anticipated workforce and vaccine acceptance issues, especially given the observed high demand for COVID-19 vaccination support of children 12–15 years due to anxiety and needle distress. As such, when the Comirnaty (Pfizer-BioNTech) COVID-19 vaccine was approved in Australia for children 5–11 years, development of a tailored vaccination pathway for primary school children became a key priority of the Victorian State government, with the hope to optimise vaccine acceptance and coverage in this age group.

The community pressure and political will to vaccinate primary school children in Australia escalated in late 2021 as the United States, Canada and other countries began COVID-19 vaccine programs in this age group [12], [13]. Separate to direct protection for children, it was hoped that high uptake of COVID-19 vaccines in children would partially reduce community transmission and the observed impacts of school closures and disruption to children’s education, wellbeing, and development [14], [15], [16], [17], [18]. The Australian Technical Advisory Group on Immunisation (ATAGI) recommended vaccination with Pfizer-BioNTech COVID-19 vaccine for children 5–11 years on 9 December 2021, with the rollout commencing in Victoria, Australia, on 10 January 2022 [19]. Two dose COVID-19 vaccine coverage for adults over 16 years in Australia is now >95% [20]. However, uptake varies across Local Government Areas (LGA) due to both access and acceptance issues, more prominent in many culturally and linguistically diverse (CALD) and Aboriginal and Torres Strait Islander communities, amongst people with disabilities and in other high-risk groups [21]. Different strategies are needed and have been shown to work to address vaccine hesitancy and practical issues [22], [23]. In Australia, the Federal government is responsible for selecting and purchasing vaccines, safe transport to administration sites, specifying priority populations (based on advice from ATAGI), establishing overall principles and minimum requirements for vaccination locations and workforce, clinical governance, and developing and delivering the national communications campaign [24]. The State government is responsible for providing appropriately trained workforce, identifying vaccination sites, and creating an implementation plan to identify how priority groups will be reached. COVID-19 vaccines are administered through both State and Federal run vaccine programs, with the Federal government responsible for vaccinations undertaken in primary care, aged care facilities, and pharmacies, and the State program responsible for vaccinations undertaken in Victorian vaccination hubs. The Victorian State vaccination program administers approximately a quarter of the COVID-19 vaccines across age groups (28% of total vaccine doses delivered to this age group in Victoria over the survey period) compared to vaccines administered through the Commonwealth-run program. However, the State vaccination program was more able to tailor their program to target high risk areas and groups with expected lower vaccine coverage. Ensuring high uptake for priority communities was central to delivery of the 5–11-year COVID-19 vaccination rollout in the Victorian vaccination hubs, especially as there was no existing school-based vaccination program for primary school children which only exists in the secondary school setting.

In Victoria, the second most populous state in Australia, the Victorian Department of Health (DH) undertook comprehensive and early planning to ensure high accessibility and a positive experience for children 5–11 years. A tailored and bespoke pathway was designed to support primary school children with existing procedural anxiety, developmental behavioural needs, or intellectual or physical disabilities. The pathway included a child-friendly themed environment called the ‘Enchanted Forest of Protection' with staff trained in paediatric vaccination, an online immunisation plan for parents to guide booking of the immunisation appointment for their child, and supports for children with additional needs, including distraction measures, low sensory environments, and hospital-based sedation pathways.

This study assessed the parent-reported experience of children 5–11 years who received a COVID-19 vaccine at state-run Victorian vaccination hub. The aim of the study was to understand a) the overall parent-reported experience of the vaccination program; b) the uptake and usefulness of the immunisation plan; c) which children required extra support and d) what supports were utilised and their benefits.

2. Methods

2.1. Program design

The Victorian Department of Health’s Enchanted Forest of Protection program was designed for children 5–11 years according to the key principles of: a) a safe, child friendly environment; b) experienced staff trained in use of distraction techniques; and c) adequate availability of supports for children tailored to different levels of need. Further details of the program planning and implementation are described below.

2.2. Hub layout

The Enchanted Forest of Protection program was rolled out in over 58 state vaccination hubs across metropolitan and regional Victoria, with smaller programs and collateral available through general practice and pharmacies. Hub locations were selected to prioritise areas with anticipated lower levels of vaccine coverage. The location of hubs vaccinating children 5–11 years, and from which parents/guardians received the survey, can be seen in Fig. 1 . All vaccination hubs were required to be accessible for prams and wheelchairs, with priority queues for children. The layout of the program for children aged 5–11 years within the state vaccination hubs was primarily designed to minimise waiting time and maximise ease of attendance for families. This included large booths to accommodate prams, longer appointment times than for adults, attendance of younger siblings and facilitation of multiple children in a family being vaccinated at the same time, as well as initial or booster doses for their parents/guardians.

Fig. 1.

Fig. 1

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Location of state-run vaccination hubs where respondents attended for vaccination of children aged 5–11 years (Microsoft product screen shot reprinted with permission from Microsoft Corporation).

2.3. Child friendly environment

To create a positive, child-friendly environment, hubs were decorated with an Enchanted Forest of Protection nature theme including playful imagery of native Australian animals, rivers and bush, plus a vaccination tree that ‘grew’ when a child (or adult) wrote their name on a leaf sticker and added it to the tree after being vaccinated (Fig. 2, Fig. 3 ). This vividly illustrated growing immunity across local communities for families – ‘the bigger the tree gets, the safer we all will be’[25]. The hubs used pictorial decals for wayfinding and posters at children’s height. Activities conforming to appropriate infection prevention control (wipeable or single use) were available, including games, activity bags with stickers, First-Nations-themed stories and colouring books, coloured pencils, and fidget spinners.

Fig. 2.

Fig. 2

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An ‘Enchanted Forest of Protection’ vaccination hub site.

Fig. 3.

Fig. 3

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Vaccination tree with named stickers from children (green) and adults (brown) following vaccination. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

A tiered approach to vaccination was created to accommodate different levels of support needs (Fig. 4 ), and clinicians were provided with a flow chart to help guide decision making. Several studies have demonstrated the benefits of therapeutic play and distraction, including use of virtual reality in reducing procedural anxiety in children [26], [27], [28], [29], [30], [31]. This informed the provision of specific resources for distraction, including small devices such as the “BUZZY®'' bee vibrating device, cool wand device and a minimum of one Smileyscope virtual reality headset per hub (Fig. 5 ) [32], [33]. The virtual reality headsets use evidence based virtual reality to alleviate fear during medical procedures by reframing real world sensations in a virtual reality world i.e., swimming in an underwater sea scene. GPs and pharmacies were not provided with these devices so parents were encouraged to book at a state vaccination hub if they anticipated their child would benefit from this level of support or higher.

Fig. 4.

Fig. 4

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Tiered approach to levels of support for vaccination of children aged 5–11.

Fig. 5.

Fig. 5

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Smileyscope virtual reality headsets.

2.4. Vaccination of children with needle phobia or neurodevelopmental conditions

Children with greater needs or a disability were guided either to a vaccine hub or to call a Disability Liaison Officer (DLO) who could assist in identifying additional community support a child may require. DLOs were available on site or via phone, working collaboratively with vaccination teams. Select flagship vaccination hubs also provided low volume, low stimulus sessions with reduced light and noise for children with autism and sensory difficulties. Additional higher-need pathways were available for escalation of supports including in-home vaccination or awake sedation. Vaccination under sedation was administered through a hospital-based sedation pathway through the Victorian Specialist Immunisation Services (VicSIS) [34].

2.5. Immunisation plan

Promotion through the Victorian Department of Health and primary care encouraged parents to complete an online Immunisation Plan on the Coronavirus.vic.gov.au website prior to their appointment [35], [36]. The plan was designed by a specialist immunisation paediatrician to make vaccination a positive and supported experience by helping parents identify ahead of time what support their child might need on the day of vaccination e.g., identifying the best support person to attend with the child, which items to bring (e.g., favourite toys, digital tablets). The immunisation plan also helped parents determine the most appropriate location for vaccination based on level of support required (e.g., general practice, pharmacy, state vaccination hubs or more tailored models, and increasing level of support such as in-home or hospital-based sedation) [35].

2.6. Staff training

Victorian local councils routinely administer a significant proportion of non-COVID paediatric vaccines. Given their expertise with this cohort, several of these local councils were recruited to help provide in-person training sessions to state-run vaccination hub staff. Melbourne Vaccine Education Centre (MVEC) designed and presented the theoretical, online, foundational training module and provided clinical supervision at selected council sites [37]. Key objectives of this training were to upskill vaccinators in appropriate holding techniques and utilisation of distraction, as well as parameters to abort a vaccination attempt [37].

Smileyscope ran training sessions with vaccine hubs to educate immunisers on the use of the virtual reality headsets. Additionally, nine experienced paediatric nurse immunisers were employed by DH to support the program. Working in a roving capacity across the state they assessed competency, reinforced instruction, and provided remedial training where needed.

2.7. Evaluation of the vaccination experience

2.7.1. Participants and recruitment

All parents/guardians of a child aged 5–11 years who received a dose of a COVID-19 vaccine at a state-run vaccination hub across Victoria (regional and metropolitan) were invited to complete a post vaccination survey. Parents/guardians of children who received two doses of a COVID-19 vaccine in the study period were invited to complete the post vaccination survey on both occasions.

2.7.2. Ethics

The data from this survey were initially collected as a service quality improvement measure. Subsequently, an application was submitted for ethics approval to share and analyse the aggregated and de-identified data. Ethics approval was obtained from the Royal Children's Hospital Human Research Ethics Committee (HREC/82021).

2.7.3. Consent

Completion of the survey was voluntary. Parents/guardians who completed the survey were advised that their responses would be anonymous.

2.8. Data collection

Survey data collection by the Victorian Department of Health occurred between 9 February and 31 May 2022. The survey was administered electronically and could only be completed in English by the child or their parent/guardian but not both. This was a feature of the survey also being sent to individuals aged 12–15 years receiving a dose of a COVID-19 vaccine. It is assumed, however, that most surveys for children aged 5–11 years would have been completed by a parent/guardian and so we have referred to participants as such for the purposes of this paper. No identifiable data were collected. The survey was created using Microsoft Power Apps and data were stored in Microsoft Dataverse and is owned by DH.

2.9. Data measures

The survey was restricted to 16-items to optimise the response rate and not overwhelm parents/guardians. The survey included questions about location of respondents (postcode), Aboriginal or Torres Strait Islander (Australia’s First Nations peoples) status, first language other than English, or disability or special needs of the child. The survey ascertained overall parent/guardian-reported rating of the vaccination experience on a 5-point rating scale, usefulness of the pathway, additional support required for vaccination and reasons why (e.g., anxiety about receiving the vaccine, autism) and supports utilised. Respondents were asked if they utilised the Victorian Department of Health immunisation plan (yes/no) and about its usefulness as one of a list of support measures. Parents/guardians could select multiple options for each question. If respondents selected “child used virtual reality headset”, further questions regarding reduction in the child’s anxiety and ease of use of the headset were asked. Demographic questions and rating of overall experience at the vaccination hub were mandatory but questions around support were voluntary. The survey can be accessed at https://cvms-survey.powerappsportals.com/form/.

2.10. Data analysis

Microsoft Power BI (version 2.104.702.0) was used for data analysis. Categorical variables are presented by number and percentage and analysis stratified by demographics, location, and specific group (e.g., children with disability or special needs, children with a first language other than English), as well as need for additional support. Analysis of which measures were reported useful for vaccination (noting multiple responses could be selected) and reason for requiring additional support was undertaken (e.g., autism, sensory issues, procedural anxiety).

3. Results

3.1. Overall

83,350 doses of a COVID-19 vaccine were administered to children aged 5–11 years at Victorian state vaccination hubs from 9 February to 31 May 2022 (including dose 1, dose 2 and additional doses). This represents 28.2% (83,350/295,405) of total vaccine doses delivered to this age group in Victoria over this period, with the majority of the 295,405 5–11-year-old vaccinations delivered through primary care and pharmacies. There were 9,203 survey responses received (11.0% of doses administered by the state), with location of respondents seen in Fig. 6 . There was a high proportion of regional respondents (40.8%) when compared with resident population distribution, with 23.0% of Victorians living in regional areas according to national census data in June 2021 [21], [22].

Fig. 6.

Fig. 6

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Number of survey responses by Local Government Area (heat map).

The demographic characteristics of the children represented by participants can be seen in Table 1 . Of the total 9,203 children vaccinated for whom a survey was completed, 1.5% (142/9203) were Aboriginal or Torres Strait Islander children, higher than the Victorian population proportion of Aboriginal and Torres Strait Islanders of 0.9% in 2016 [38]; 9.4% (865/9203) had a first language other than English, a smaller proportion than the estimated 25.0% of primary and secondary school children who speak a first language other than English at home [39]; and 5.4% (499/9203) had a disability or special needs, which is also lower than the estimated proportion of children aged 5–14 years with any disability (9.3%) [40].

Table 1.

Number of respondents by demographic.

Number of respondents N (%)
Overall 9203
Metropolitan Children 5437 (59.1)
Regional Children 3759 (40.8)
Aboriginal and Torres Strait Islander Children 142 (1.5)
Children with a disability or special needs 499 (5.4)
Children with English as a second language 865 (9.4)
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Overall, the 5–11 state vaccination program was well received, with 94.4% (8687/9203) of respondents rating it as very good or excellent. One hundred and fifty (150) of 9,203 respondents (1.6%) indicated their child needed additional support to receive a COVID-19 vaccine. Reasons for needing additional support can be seen in Table 2a, Table 2b , with the most frequently selected responses being mild or high anxiety about receiving the vaccine (58.0%; 87/150 and 28.0%; 42/150, respectively) and autism (28.0%; 42/150).

Table 2a.

Number and percentage of respondents to the optional question regarding reasons that children needed additional support for vaccination.

Number and percentage of respondents
Overall Metropolitan Children
N (%) 		Regional Children
N (%) 		Aboriginal and Torres Strait Islander Children
N (%) 		Children with a disability or special needs
N (%) 		Children with first language other than English
N (%)
150 99 (66.0%) 51 (34.0%) 1 (0.7%) 44 (29.3%) 11 (7.3%)
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Table 2b.

Reasons that children needed additional support for vaccination. Participants could select more than one response.

Reason for needing additional support (multiselect) Overall
N (%) 		Metropolitan Children
N (%) 		Regional Children
N (%) 		Aboriginal and Torres Strait Islander Children
N (%) 		Children with a disability or special needs
N (%) 		Children with first language other than English
N (%)
150 99 (66.0%) 51 (34.0%) 1 (0.7%) 44 (29.3%) 11 (7.3%)
Mildly anxious about receiving the vaccine 87 (58.0) 55 (55.6) 32 (62.7) 0 23 (52.3) 5 (45.5)
Autism 42 (28.0) 30 (30.3) 12 (23.5) 0 36 (81.8) 1 (9.1)
Highly anxious about receiving the vaccine 42 (28.0) 29 (29.3) 13 (25.5) 0 8 (18.2) 4 (36.4)
A previous negative experience with vaccination or procedures 37 (24.7) 26 (26.3) 11 (21.6) 1 (100.0) 12 (27.3) 0
Sensory issues 27 (18.0) 15 (15.2) 12 (23.5) 0 21 (47.7) 0
A physical, intellectual, or developmental disability 19 (12.7) 10 (10.1) 9 (17.6) 1 (100) 14 (31.8) 0
Behavioural issues 16 (10.7) 8 (8.1) 8 (15.7) 0 13 (29.5) 1 (9.1)
Other 9 (6.0) 6 (6.1) 3 (5.9) 0 2 (4.5) 0
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The measures respondents identified as being helpful or used to support the child to have their COVID-19 vaccine can be seen in Table 3a, Table 3b . The most frequently selected responses were the child-friendly staff (88.5%; 255/288), the “Enchanted Forest of Protection'' child-friendly environment (66.3%; 191/288), and use of distraction techniques such as “BUZZY®'' bee or cool wands (39.6%; 114/288). A total of 13.5% (1244/9203) of respondents completed the immunisation plan for their child before the appointment. Use of the immunisation plan overall and by different priority groups can be seen in Table 4 . Of the respondents who answered the question about measures that were helpful or used to support their child to have a COVID-19 vaccine, 18.4% (53/288) selected use of the immunisation plan and 15.3% (44/288) use of the virtual reality headset. Of those who selected use of virtual reality headset, 68.2% (30/44) found it to be useful to reduce their child’s anxiety, and 72.7% (32/44) reported experiencing no difficulties in using the device. The questions asked to understand reasons children needed additional support, the measures that were helpful or used in this context, and use of the immunisation plan were all optional and therefore the denominator for these questions differs to the denominator for total survey respondents.

Table 3a.

Number and percentage of respondents who answered the optional question about measures that were identified as helpful or used to support children to have their COVID-19 vaccine.

Number and percentage of respondents
Overall
N (%) 		Metropolitan Children
N (%) 		Regional Children
N (%) 		Aboriginal and Torres Strait Islander Children
N (%) 		Children with a disability or special needs
N (%) 		Children with English as a second language
N (%)
288 193 (67.0) 95 (33.0) 8 (2.8) 54 (18.8) 41 (14.2)
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Table 3b.

Measures that were identified as helpful or used to support children to have their COVID-19 vaccine. Participants could select more than one response.

Number and percentage of respondents
Measures that were helpful or used to support children to have their COVID-19 vaccine (multiselect) OverallN
(%)		 Metropolitan ChildrenN
(%)		 Regional ChildrenN
(%)		 Aboriginal and Torres Strait Islander ChildrenN
(%)		 Children with a disability or special needsN
(%)		 Children with English as a second languageN
(%)
288 193 95 8 54 41
The staff were child friendly 255 (88.5) 172 (89.1) 83 (87.4) 8 (100.0) 47 (87.0) 35 (85.4)
The child friendly environment (the Enchanted Forest of Protection) 191 (66.3) 125 (64.8) 66 (69.5) 4 (50.0) 28 (51.9) 34 (82.9)
The clinic offered other ways to distract my child i.e., cool wands, buzzy bee 114 (39.6) 79 (40.9) 35 (36.8) 1 (12.5) 24 (44.4) 15 (36.6)
There was a low sensory, quiet environment 79 (27.4) 54 (30) 25 (26.3) 2 (25.0) 28 (51.9) 11 (26.8)
We brought toys, music and/or a device from home 70 (24.3) 48 (24.9) 22 (23.2) 1 (12.5) 27 (50.0) 3 (7.3)
The immunisation plan gave my child some control over the process 53 (18.4) 36 (18.7) 17 (17.9) 1 (12.5) 12 (22.2) 13 (31.7)
They used a virtual reality headset 44 (15.3) 25 (13.0) 19 (20.0) 1 (12.5) 10 (18.5) 0
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Table 4.

Use of the Department of Health Immunisation Plan. This was an optional question.

Use of the immunisation plan
Overall
 Metropolitan Children Regional Children Aboriginal and Torres Strait Islander Children Children with a disability or special needs Children with English as a second language
Total number of respondents to the question about use of the immunisation plan 9203 5437 3759 88 216 179
Used the immunisation plan N
(%)		 1244 (13.5) 824 (15.1) 419 (11.1) 23 (26.1) 33 (15.3) 42 (23.5)
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3.2. Aboriginal and Torres Strait Islander Children

Parents/guardians of Aboriginal and Torres Strait Islander children rated the program positively with 95.8% (136/142) rating it as very good or excellent. More than a quarter of all guardians of Aboriginal and Torres Strait Islander children used the immunisation plan (26.1%; 23/88 compared with 13.5%, 1244/9203 in the overall sample). However, there was a lower reported need for additional support (1.1%; 1/88 compared with 1.6%, 150/9203 in the overall sample). The measures most frequently selected as being useful or used to help a child receive a COVID-19 vaccine were the child-friendly staff (100.0%; 8/8) and child friendly environment (50.0%; 4/8), similar to the broader cohort.

3.3. Children from culturally and linguistically diverse communities

Parents/guardians of children with a first language other than English similarly rated the vaccination program positively, with 92.6% (n = 801/865) rating it as very good or excellent. A much higher proportion of families utilised the immunisation plan prior to vaccination than in the general population (23.5%; 42/179 vs 13.5%; 1244/9203). Only 7.3% (11/150) of those respondents indicating their child needed additional support were guardians of children from CALD communities. Reasons for needing additional support were the same as for children overall, including child-friendly staff (85.4%; 35/41) and child-friendly environment (82.9%; 34/41). Parents/guardians of children with a first language other than English also rated the immunisation plan as being useful to give their child some control over the process at higher rates than the general population (31.7%; 13/41, compared with 18.4%; 53/288).

3.4. Children with a disability

Parents/guardians of children with a disability rated the program as very good or excellent (93.2%; 465/499 vs 94.4%; 8687/9203) and used the immunisation plan (15.3%; 33/216 vs 13.5%; 1244/9203) as frequently as respondents overall. However, respondents rated the immunisation plan as being useful to give their child some control over the process more highly (22.2%; 12/44 vs 18.4%; 53/288). The most common reason for needing additional support was autism (81.8%; 36/44) rather than procedural anxiety as for other cohorts, with the next most common reason being a physical, intellectual, or developmental disability (31.8%; 14/44). Respondents selected low sensory environment (51.9%; 28/44 vs 27.4%; 79/288) and bringing distraction from home (50.0%; 27/4 vs 24.3%; 70/288) more highly as useful support measures. Respondents selected virtual reality and other distraction techniques being useful for successful vaccination at a similar frequency to respondents overall (18.5%; 10/44, vs 15.3%; 14/288 and 44.4%; 24/54 vs 39.6%; 114/288 respectively).

3.5. Regional vs urban populations

Parents/guardians of children in metropolitan and regional areas similarly rated the program as very good or excellent (94.1%; 5115/5437 vs 94.9%; 3566/3759). Fewer families completed the immunisation plan in regional compared with metropolitan areas (11.2%; 419/3759 vs 15.2%; 824/5437). Similar proportions of children needed additional support regardless of location (1.8%; 99/5437 metropolitan vs 1.4%; 51/3759 regional). A child being mildly anxious about receiving the vaccine was the most frequently selected reason for needing additional support for children in both metropolitan (55.6%; 55/99) and regional (62.7%; 32/51) areas. Staff being child-friendly, and the child-friendly environment were the most frequently selected support measures by families of children in both regional and metropolitan areas.

4. Discussion

The Victorian Department of Health ‘Enchanted Forest of Protection’ vaccination program was the first of its kind to use a child and family-centred design pathway to provide an optimal environment for vaccinating children 5–11 years. To our knowledge, there have been no studies focusing on a tailored and bespoke vaccination pathway for children to reduce needle distress and improve uptake. Our evaluation demonstrated very high satisfaction with the child-friendly vaccination program (93.0–96.0%), with the highest satisfaction amongst parents of Aboriginal and Torres Strait Islander children (96.0%), and the paediatric experience of staff and child-friendly environment rated as the most important elements. This study demonstrates the effectiveness of targeted workforce training and ensuring families are at the centre of the design of a vaccination program.

The immunisation plan was utilised by 13.5% families overall, with higher use amongst parents/guardians of Aboriginal and Torres Strait Islander (26.1%) and CALD (23.5%) children, indicating greater usefulness within these priority communities. The question on use of the plan was not mandatory and therefore use may be underestimated but the low uptake overall indicates a need for more widespread promotion and awareness, especially given fewer parents/guardians in regional areas completed the plan than in metropolitan areas. The low sensory environment and bringing distraction supports from home were utilised more frequently by parents of children with a disability than for the general population, suggesting the importance of pre-planning and of having a tailored pathway for children with additional needs.

Non-pharmacological interventions such as distraction activities and therapeutic play have long been used in paediatrics to reduce needle distress and procedural anxiety and pain in children [26], [30], [41], [42]. The training of staff at vaccination centres in use of these techniques had a substantial impact on families’ experience of vaccination, with experienced paediatric staff being selected as one of the most frequent supports aiding successful vaccination. Virtual reality technology is increasingly being used to improve the experience of children requiring procedural intervention. Several randomized control trials have demonstrated that virtual reality can significantly reduce procedural pain and needle distress in children [27], [28], [29]. This was in keeping with our finding that of those children who used the virtual reality headsets, more than two thirds found it useful in reducing their child’s anxiety. Delivery of the 5–11-year-old vaccination program was limited by time pressures and further preparation time would have allowed more extensive of training of staff.

In Victoria, 45.2% of children aged 5–11 have received at least 2 doses of a COVID-19 vaccine with higher single dose uptake (61.0%) [21]. While this coverage is relatively low compared with people over 16 years (>95.0%), it is higher compared to many other states in Australia, except for Tasmania (62.7% first dose coverage) and the Australian Capital Territory (78.0% first dose coverage) [43], [44]. Victorian COVID-19 vaccine coverage is higher than national single and two dose coverage (52.3% and 40% of children aged 5–11 years, respectively) [45]. Victorian COVID-19 two dose vaccine coverage for this age group is also higher than in other countries such as the United States (29.0%), Canada (42.3%) and England (10.6%) [46], [47], [48]. While this cannot be attributed directly to the ‘Enchanted Forest of Protection’ vaccination program, high parental satisfaction suggests that these measures were important factors in successful vaccine uptake. The 5–11 year old child vaccination program also occurred in the context of the BA.2 Omicron COVID-19 variant wave of cases in January 2022 [49], [50], just prior to the start of the school year when many parents and teachers were hopeful for in-person schooling. This context contributed to the early high vaccination rates for this age group.

Over a quarter (28.0%) of total vaccine doses delivered to this age group in the study period were administered at a state vaccination hub, with the rest being delivered in primary care and through pharmacies that did not have access to the same resources. It is therefore difficult to truly ascertain the impact of the bespoke 5–11 pathway on overall vaccine uptake in this cohort. However, the state vaccination program was specifically designed to target and focus on priority communities such as Aboriginal Torres Strait Islander children, children from CALD communities and children with a disability, for which it was successful. It will be useful to compare uptake in these priority communities with national and international data when available. It is plausible that if state and federal systems were integrated and all children with higher needs had access to child-friendly environments and distraction techniques, that uptake would be further improved in this age group. A qualitative survey of parents/guardians of children aged 5–11 years that explores views on COVID-19 vaccination regardless of child vaccination status and vaccination setting (unpublished) will further shed light on parental experience of these two different programs.

This study has some limitations. The optional nature of the survey led to a low participation rate of 11.0%, although the sample size was still sufficient to draw conclusions (9,203 responses). The survey questionnaire was limited to 16 questions to optimise the response rate and not overwhelm parents/guardians This restricted more extensive feedback on the immunisation plan, evaluation of elements of the vaccination program, and gathering more detailed information on previous negative immunisation experiences, type of disability, and specific CALD groups. In addition, the evaluation survey was sent to parents/guardians who presented with their child to a state hub for vaccination but did not ask whether vaccination was ultimately successful. However, the aim of this study was to assess the overall immunisation experience rather than successful vaccination. The participation of families from CALD communities and parents/guardians of children with a disability was lower than expected based on census data. This may have been due to the survey only being available in English or distribution pathways. Many of the vaccination program experience questions were not mandatory to complete and thus impacted the sample size of responses obtained. The Enchanted Forest of Protection vaccination program was only rolled out in state vaccination hubs and only parents/guardians of children vaccinated in this setting received the survey, which represents 28.0% of total children receiving a vaccine dose in this time period. Use of the immunisation plan in primary care (GPs and pharmacies) was not ascertained and should be further studied.

5. Conclusion

The COVID-19 Enchanted Forest of Protection tailored vaccination program for children 5–11 years in Victoria had a very high satisfaction rating amongst parents and facilitated early high and rapid vaccine uptake in vaccination hubs. The Immunisation plan guided parents to access the required level of support for their child and was used more frequently by priority groups. Positive, child-friendly vaccination environments reduce anxiety, support children with needle distress and provide targeted services for children with specific needs. This approach should be utilised for COVID-19 vaccination in younger children and for future paediatric vaccination programs, especially pandemic or mass vaccination programs.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

Victorian Department of Health COVID-19 Vaccination Program staff, Naomi Bromley, MCRI Vaccine Uptake Group, MVEC, SAEFVIC, Prof Nigel W Crawford, Prof Jim P Buttery

Data availability

Data will be made available on request.

References

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data will be made available on request.

Articles from Vaccine are provided here courtesy of Elsevier

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