Involving stakeholders in informing the development of a Knowledge Translation (KT) intervention to improve the vaccination experience at school

Abstract

Objective

Pain, fear, and fainting management during school-based vaccinations is suboptimal. The objective was to examine stakeholder perceptions of barriers and facilitators to better practices. Method: Six semi-structured focus groups were conducted in Niagara Region, Ontario: two parent groups (n=7); one grade 7 to 8 student group (n=9); two nurse groups (n=12); and one school staff group (n=6). Participants shared perceptions about school vaccination clinics and the implementation of specific strategies and tools. Focus groups were audio recorded and transcribed. The Consolidated Framework for Implementation Research (CFIR) was used as the framework for analysis.

Results

Feedback from stakeholders was categorized into four domains of CFIR: intervention characteristics, inner setting, outer setting, and characteristics of individuals. Intervention characteristics included: vaccine educational materials, vaccination accommodations, distraction techniques, topical anaesthetics, and food. Inner setting factors included: school vaccination procedures, relationships between school staff and nurses, assessment and documentation of student fear, and factors that contribute to a chaotic vaccination clinic. Outer setting factors were: the social environment and addressing parent and student needs. Stakeholder roles were discussed in characteristics of individuals.

Conclusion

This study identified elements that can facilitate and challenge pain and fear mitigation tools and strategies; these elements should be considered in the development of a Knowledge Translation (KT) intervention to improve the school vaccination experience.

Immunization is one of the most important public health interventions of the last 50 years and has led to the control or elimination of many preventable diseases (1). School-based mass vaccinations play an integral role in preventing diseases in school-age children in Canada. Vaccine administration, however, involves painful injections that can cause stress, or even fainting (2,3,4). Needle fear may cause avoidance of vaccines and blood tests or negative emotional and physical reactions to such procedures that last a lifetime (4,5). Adults may model needle fear to their children, thereby perpetuating the cycle over generations (4).

Although research has demonstrated many effective pain and fear interventions, there is a dearth of data for school-based vaccinations (6). The World Health Organization and Public Health Agency of Canada have called for efforts to address this important knowledge-to-care gap (7,8). A national interdisciplinary group, the Help ELiminate Pain in Kids & Adults (HELPinKids&Adults) Team, leading Knowledge Translation (KT) activities in this field, developed an evidence-based Clinical Practice Guideline (CPG) for mitigating vaccine injection fear, pain, and fainting (9). Specific KT tools for the school-based vaccination context were not included due to the lack of primary research in this setting.

Selected members of the CPG panel partnered with Niagara Region Public Health and the Niagara Catholic District School Board on a KT project to translate the CPG recommendations for the school setting (10). An overview of this project, including the process used, key tools developed, and implementation findings, is provided in a separate paper in this issue (11). In the present manuscript, we report on the results of baseline focus group interviews with the key stakeholders involved in school-based vaccinations—students, nurses, school staff, and parents—in consideration of the HELPinKids&Adults CPG recommendations (9). The results, combined with existing literature on this topic, provided the foundation for the development of a multifaceted KT intervention called The CARD™ System (C-Comfort, A-Ask, R-Relax, D-Distract) to improve school vaccination experience (11). CARD™ provides a framework for planning and delivering vaccinations that uses a student-centred approach and promotes coping. Each letter of the word C-A-R-D stands for a group of interventions that can be used to reduce vaccination-associated pain, fear, or fainting (see overview article in this series) (11).

METHODS

Participants, recruitment, and setting

Participants included students, parents, school staff, and public health nurses from Niagara, Ontario. Students in grade 7 or 8 were eligible. Parents of children of any age were included. Only school staff and nurses with experience with school vaccinations were eligible. Purposive sampling was used to provide a diverse range of individuals with different school vaccination experiences, sex/gender, and socio-economic status.

Recruitment settings were identified in collaboration with participating organizations including: local public health unit, school board, and the Canadian Family Advisory Network. Eligible students, school staff, and parents were invited to participate by the school principal or public health unit. Public health nurses were invited by the public health unit manager. All participants signed a consent form. Parents also provided consent on behalf of their children. The study was approved by the Research Ethics Boards of the University of Toronto and the Niagara Catholic District School Board.

Focus groups were held on six separate occasions and at different locations to facilitate attendance: students and nurses at public health headquarters; parents at public health headquarters or a neighbourhood community centre; and school staff at their school.

Procedure

Using a semi-structured interview guide, a facilitator asked participants, using code names, to describe: their experiences with school-based vaccinations; barriers and facilitators to a positive school vaccination experience; specific needs and preferences for pain, fear and fainting mitigation interventions and learning preferences; required resources (i.e., time, personnel, technology); and feasibility of the integration of pain, fear, and fainting interventions in existing processes and infrastructure. Participants reviewed and commented on the following template materials (not included): two videos (one about vaccination and the other about pain and fear mitigation); slide presentation (general information about vaccination, the vaccines given, and pain, fear and fainting mitigation interventions); and a pamphlet with information about vaccination and pain, fear, and fainting mitigation. These tools were used to elicit discussion regarding participant preferences about the type and extent of education and optimal education delivery methods. All focus groups lasted approximately 1 hour and were audiotaped; field notes were also taken. Audiotapes were transcribed verbatim after the session. Participants also provided written feedback on the tools and demographic information (e.g., sex, age, position—school staff and public health nurses; grade—students).

Sample size and analysis

The sample size was set at 3 to 12 individuals for each of the six focus groups. Focus group discussions were analyzed using directed content analysis (12) guided by the Consolidated Framework for Implementation Research (CFIR) (13). CFIR provided a framework for the barriers and facilitators, needs of stakeholders, resources, and feasibility of integration of pain, fear, and fainting mitigation interventions in the school vaccination program. Two researchers read through each transcript and identified salient themes that related to the CFIR domains and subdomains. A third researcher reviewed the coding of the data for each transcript. When coding disagreements arose, the three researchers deliberated and reached a consensus.

RESULTS

The study was conducted between November 16, 2016 and April 28, 2017. Six semi-structured focus groups were conducted: two parent groups (n=7); one student group (n=9); two groups of nurses (n=12); and one school staff group (n=6). The characteristics of the participants are described in Table 1.

Table 1.

Demographic characteristics of participants*

	Age in years	Female sex
Students (n=9)a	12.8 (0.7)	5 (55.6)
School staff (n=6)b	39.8 (6.1)**	4 (66.7)
Public health nurses (n=12)c	45.8 (13.0)	11 (91.7)
Parents (n=7)	39.3 (7.5)	7 (100.0)

*Values are mean (standard deviation) or frequency (percent).

**n=5.

^an=6 grade 8; n=3 grade 7.

^bn=4 teachers, n=1 principal, n=1 resource teacher.

^cn=7 vaccine clinic injecting and charge nurses; n=5 school nurses.

Themes from four of the five domains of CFIR (13) emerged from the focus group discussions: 1) intervention characteristics; 2) inner setting or the nature of the environment/organization where the intervention may be used; 3) outer setting or the social, economic, and political environment where the intervention may be used; and 4) characteristics of the individuals involved with the intervention and the implementation processes, including knowledge and beliefs. Each domain is described below with examples of quotes provided in Table 2; although some content was relevant to multiple themes, results will be discussed theme by theme for simplicity.

Table 2.

Participant quotes

CFIR* category	Theme	Quote
Intervention Characteristics	Educational materials about vaccination - content, use, timing	I don’t even know that much about needles and what I’m supposed to need and it’d be good if I was able to educate myself. - Student 1
		Our classroom, dreads the (usual nurse slide) presentations, ‘ugh it’s the needle presentations’ cause, it’s just basically a nurse standing in front of our class like ‘okay so you’re getting a needle, this is what it is… If it’s a learning video, at school of kids our age … seeing some kids that are scared and some kids that aren’t … what would basically be going on the day that it happened…then what? - Student 3
		…If you have a video and you can relate to the video, [with] a character in this video and they’re very nervous to get their needle but when it’s done they notice it wasn’t that bad, you can relate to them, I think that would be a good idea. – Student 1
		…So, we have a presentation then we get our pamphlets, no one reads them. Mom might be like ‘Oh my god, yeah, let’s read this’ but then we throw it out anyways. – Student 4
		If the teachers took even 5 minutes of their day- the day before or whatever, just to explain this is what’s going to happen, this is why you’re getting it, the importance of why you’re getting it. Then the students will be more prepared and then at the same time, it will be right fresh in their brain for them to go home and talk to the parents about it. They’ll be like ‘Mom, I’m getting a shot tomorrow.’ Especially if they’re scared, then we’re prepared and they’re prepared. – Parent 4
	Clinic setting accommodations	…So having a friend with you makes it better. – Student 5
		Rather than being there with everyone and seeing everyone, I’d rather, when we get our needles, there’s a small room. I’d rather go there only with the nurse and do it … to calm me down. –Student 1
		I don’t think that it would really matter if you had your parents there or not because if you’re with your parents it’s kind of the same as being with your friends because you have somebody there to support you when you’re getting the needle. – Student 4
	Psychological strategies	I know for my younger daughter, if she’s able to sit there with like a video game or something … like focus on that, that would help her so much going forward. - Parent 1
		Well, one of the friends in my class, [the nurse] was pretty strict and she didn’t say anything, she just put it in into his arm and he wasn’t ready for it … he was not very happy with it because she just did it without saying anything. – Student 6
	Topical anaesthetics	There are very few people that had the patches … Parents [put on] the patch above the elbow. You have a site that is now numb but out of the area that we need and then we had to give it into the arm where they were having some pain. Giving more education as to where exactly to put the patch to best allow us to do our job and for them to have less pain in the process. – Nurse 1
		I like the idea that in the pamphlets, they were talking about the (brand name of topical anaesthetic) patch and different things because I didn’t know any of that ... until my doctor was like ‘Okay, we had enough of this. Go [get a topical anesthetic].’ Had I known before, maybe the stress would be a lot less at that point. – Parent 2
	Food	I think if candies were offered at the end, people would probably look forward to it and they wouldn’t be nervous about it. – Student 7
		If a parent sees this [pamphlet] and thinks ‘Oh my gosh…I need to give a healthy breakfast. Where am I going to find breakfast?’ you’re not contributing to lowering their anxiety, you’re actually increasing it. – Parent 5
Inner Setting	Vaccinations at school vs. other settings	In terms of the school setting, I appreciate it. It’s one thing I don’t have to wait the extra 15 minutes. It’s one less trip that I have to do and you know, I know that it’s done… It’s a safe environment, it’s convenient. And there’s something to be said about knowing his other peers are also being vaccinated. So I know that they’re safe. So that is ideal. – Parent 3
		Giving parents the option … there may be parents that’ll say ‘Oh yes, that’s a good idea. I’ll take them to a clinic’ but then life gets in the way and then they don’t get vaccinated and then, you know, they just forget about it. – Nurse 2
		My oldest son is autistic and has sensory issues … [he needs] his own room, not where they would usually have anybody … With everybody coming at this school and everybody’s standing in line, that doesn’t really work for my son. – Parent 2
	Roles and interactions of school staff and nurses	We are very detached from (the vaccination clinic). - School Staff 1
		…The teachers, the principals, sometimes they’re the ones that come down to the library and say, ‘Hey! Give this kid the big rusty needle…’ yeah, they’re really not great sometimes. – Nurse 3
	Assessment and documentation of student fear	Is it realistic when a child’s coming in and you’re trying to say, ‘Okay, how are you feeling, tell me,’ you’re exploring how their anxiety, their fears, you maybe just ramping it up, and now you’ve got to give the injection… you don’t wanna like exacerbate on the anxiety. – Nurse 4
		…[documenting] by omission with the kids who handle it well and by documenting more deliberately for the kids who are high fear and high anxiety but perhaps it would help guide our conversations with them second and third round, if we can say, look! The nurse ticked this. Everything kind of went well, see, you have nothing to worry about this time. – Nurse 3
	Factors contributing to a chaotic vaccination clinic	The first round is the most chaotic, there’s papers everywhere, there’s missing consents, there’s papers filled out incorrectly, there’s papers filled out in pencil even though we stress it needs to be in pen. – Nurse 5
		So a lot of the teachers are set-up on apps [that allow for communication between schools and parents]. So if they sent a message [reminding about vaccination day], you’d get a text to your phone or to your email. So that’s really good to know because I’m not a paper person … And then the timing of when it comes out. Don’t send it out way too far in advance, we’ll forget. Maybe the week prior would be beneficial, the beginning of that week on the Friday, then it’s near. – Parent 4
Outer Setting	Social Environment	Like, at school, everyone’s like um ‘Oh my gosh, we’re getting needles, oh my gosh, we’re getting needles, I’m so scared’. – Student 2
		…[Students] are quite worried about what the process is going to be and what in particular- what the pain level is going to be for them, and I think they get a lot of sympathy from their peers. On the opposite end of things, I think the adults we are almost a little bit flippant towards it because we know as adults, we’ve been to the doctor many times … and you know that the little pinch that they are going to get is pretty minor compared to the invasiveness of some of the other tests as we get older. – School Staff 2
		Sometimes [nurses] can be a little rough on the children and saying like ‘Suck it up, buttercup’. – Student 5
		…We’re all fine with it and when one person didn’t feel that good after, we all helped and stuff like that. – Student 6
	Helping parents address student needs	I think [pain management] is important. If someone explains to you what you can expect and you can have an idea ‘this is normal’ and at the same time, for parents to prepare so they can know the information to tell the children [so they] know what to expect. And then at the same time, it helps with after care. – Parent 4
Characteristics of Individuals	Students	I think, when you see everyone doing it, it’s a normal thing but if you had choices … knowing you have that choice might make you feel like more comfortable with [getting the needle]. – Student 1
	School Staff	…When I see a child is in distress or really anxious, I will go over and say would you like me to sit with you, … and usually they feel a lot better knowing that someone is beside them that they are familiar with and that they trust. – School Staff 3
		I think what would help reduce their anxiety, maybe asking the kids outright who’s worried or anxious and maybe having them go separately as well, ahead of time…Honestly, we have an idea but because this isn’t our thing, when the nurses come in, they know what they are doing, they have a set-up, they do whatever the procedure is. – School Staff 4
	Parents	I think parents can play a supporting role by certainly talking it up, being positive, trying to minimize fears and alleviate the anxiety in that aspect, that it will be quick, hopefully painless, professionally done. – Parent 3
		The experience is very important because of the fact that whether it goes good or bad is gonna reflect how they feel about vaccinations going forward… when one person would cry or freak out and you’re next in line … it starts that whole fear pandemic and the anxiety for a lot of students. So that kind of trickles down and goes forward for the rest of your life. – Parent 4
	Injecting and school nurses	When I heard you say ‘do we assess their pain post-injection, and what are their comments post-injection regarding their pain and what can we do about it’, that’s an interesting comment to me. - Nurse 6 So that sounds like it was new? (Interviewer) So is this suggestion that universally we should be assessing each child’s pain after an immunization in the school clinic? I interpreted that as assessing pain beforehand to see if there’s anything to do to decrease it… but the piece that’s missing is the tick box at the end. ‘Were you satisfied? Were you happy with the way we cared for you?’ - Nurse 3
		This is going to sound horrible and I don’t mean it to sound this way but sometimes some kids just want the attention from the rest of the students, there isn’t really a fear or anxiety issue, they just are kind of known as the drama queens or kings in the classroom no matter what we’re doing, whether it’s needles, whether it’s a science project, whatever. It’s really hard to distinguish the students who truly need that support versus the ones that you know are just sort of and maybe it’s not all acting. – Nurse 5
		Crowd control. You’re really getting the kids, organizing the kids, keeping them calm before the needles, checking with the charge nurse, see if they need anything and then making sure the kids go back to class with a buddy if one doesn’t feel well, you know, keeping our eyes on them. - Nurse 5

*CFIR Consolidated Framework for Implementation Research.

Intervention characteristics

Educational materials about vaccination

All participant groups valued learning about the importance of vaccination and needle fear and pain. They stated that a gap exists between what is being taught and what students want to know about vaccination. Students reported wanting to know what to expect before, during, and after vaccinations in an in-class lesson. They expressed fear of vaccination and wanting ‘honest’ information about needle pain. Participants raised concern, however, that excessive discussion about pain and fear could potentially exacerbate student fear. They expressed a need for more readily available educational material regarding vaccination needle fear and pain. Students and parents wanted the education lesson to be given ahead of vaccination day, but not too far in advance.

All participant groups thought an educational video was preferable to the usual educational approaches which were dull lectures from a school nurse. Students, including those who had experienced needle fear, reported that videos should feature real people, as opposed to cartoons, to reflect actual experiences more authentically. All participants wanted the video to reveal a variety of techniques and strategies that each student could choose to mitigate fear and pain. Participants reported that an additional benefit of videos is that they are accessible for individual or home viewing with family and allow students who are absent on the day of the vaccination to also access the information (allaying fears that they would be ill-prepared).

All participants also reported wanting visually appealing, understandable pamphlets even though pamphlets may be discarded or lost. Both videos and pamphlets were deemed more trustworthy with a respected logo (e.g., public health, hospital). Parents and nurses wanted pamphlets to contain contact information for further inquiries. Students and parents suggested seeing actual syringes and participating in role-playing would be helpful adjuncts.

Clinic setting accommodations

All participant groups reported that it was important for students to have the ability to choose to be vaccinated in a private room rather than the usual open clinic space. While some students reported preferring being vaccinated privately in the presence of a friend or alone with the nurse, others would rather have the distraction of a big room and support of peers. Some nurses said that although they have been willing to immunize in private upon request, schools do not typically offer a private room for that purpose and vaccination clinics have had to take place in suboptimal school areas.

All participant groups thought having a support person such as a friend, parent, teacher, or school nurse present during the vaccination could be helpful, given that the injecting nurse is an unfamiliar person. Students were aware of the importance of picking a support friend who would be a calming, rather than distressing, presence. Some parents felt that a peer would be an inadequate support. All participants reported that parent presence might not be easily arranged due to parent work commitments. Some students viewed parent presence to be potentially embarrassing.

Psychological strategies

All participant groups agreed that distracting students helps mitigate pain and fear. Technological devices, such as cell phones, tablets, and music players were popular suggestions, although some students do not possess these devices and some schools prohibit them. Although nurses said in the past they have provided distracting items, like stress balls and stickers, they expressed concern about hygiene issues when these items were shared among students.

Some parents and students urged nurses to show compassion during vaccinations. Students said that engaging in conversation with a friendly injecting nurse distracts and alleviates their fear, but distant, detached or apathetic nurses can have a negative effect. Although nurses used conversation to distract while they prepared the syringes for injection, some suggested that having a small physical barrier to hide the needle preparation would be beneficial. Students and nurses thought deep breathing coached by the injecting nurse was effective to reduce pain and fear.

Topical anaesthetics

More information and training was needed on proper usage of topical anaesthetics to reduce pain during vaccination. Nurses reported that topical anaesthetics were rarely used. When used, they were often applied incorrectly, or students brought them to the clinic not yet applied. Since they require a minimum of 20 minutes of contact time before they are effective, depending on the commercial preparation being used, their use may require some planning so that they can be accommodated during the clinic. Nurses reported being unable to administer topical anaesthetics in their role and reported the need to involve others, including students, parents, and school staff. Nurses suggested that students using topical anaesthetics be identified before the clinic started to ensure that the vaccine was administered after the appropriate application waiting time. Although they supported the use of topical anaesthetics, some parents felt that the cost of the anaesthetic could be a barrier. Others stated that topical anaesthetics were justified for individual children, such as those that were fearful.

Food

Although parents agreed that eating breakfast was important to prevent dizziness during vaccination, some of them objected to using the words ‘healthy breakfast’ on educational materials to avoid promoting health inequities. All participant groups supported the idea of snacks being provided. While students wanted snacks such as candy and cookies, nurses reported that public health policies promote only healthy foods.

Inner setting

Vaccinations at school vs. other settings

All participant groups valued the convenience of school vaccinations, as opposed to arranging medical appointments or attending public health clinics. Parents felt reassured by school vaccination in that students provide mutual support, and immunization of the student body provides protection from diseases. Parents of children with unique needs, however, felt other settings were more suitable than school vaccinations because accommodations could be made, and they could attend to support their children.

All participants reported that the current vaccination process, in which students waiting in the clinic space prior to their vaccinations observe peers being vaccinated, was fear-inducing and counterproductive for both groups. Participants also felt that anxious students should be vaccinated first so that their fear would not escalate over time. Nurses proposed that waiting students be situated in the hall or other location out of sight of students being vaccinated. It was believed that school nurses and school staff should consistently take active roles in distracting waiting students with conversations or activities unrelated to vaccination. It was mentioned that lack of consistent presence of school nurses at school vaccinations was a hardship for injecting nurses, who were unfamiliar with school staff and students. Teachers suggested that school nurses consistently accompany vaccinated students back to classrooms, rather than having them walk alone in hallways.

Roles and interactions of school staff and nurses

Teachers expressed feelings of wanting to be more involved on vaccination day to contribute to a successful experience. They reported that they could provide support for and help with anxious students, but without a specific role acknowledged by the nurses, some are reluctant to be present or get involved. Nurses perceived that teachers did not interact with them as much as they would like, perhaps to avoid extra work.

Nurses felt that teachers’ attitudes play an important role in students’ vaccination experiences. Examples of teachers mocking students’ fears and inappropriate remarks about needles were given as negatively influencing the mood and environment of the vaccination clinic. Nurses expressed a need for all school staff to be educated about vaccination and appropriate behaviour. School nurses observed classroom teachers were already present at in-class lessons but felt they could be more engaged in the student education. Separately, meetings could be scheduled and written information could be disseminated to all school staff. Many teachers admitted to being poorly educated on the subject and were receptive to learning more, particularly with respect to reducing needle fear and pain so that they can provide effective support to students.

Assessment and documentation of student fear

Nurses reported there was no mandatory screening for fear or anxiety and no consistent method of identification of apprehensive students in place. They said it would be useful to be forewarned about fearful students from consent forms, phone calls, or self-identification of students. As mentioned above, despite being unsure of their role and responsibilities with respect to vaccination, teachers reported that because they know the students, they are especially qualified to discern which ones are more anxious than others, relay this information to nurses, and support individual students.

Nurses stated that they only document instances of atypical vaccine responses (e.g., fainting), rather than charting all signs of fear before, during, and after the vaccine. They reported using sticky notes to record atypical vaccine responses but that these notes could be easily lost. They suggested documentation of each student’s fear and pain level would be useful for future vaccination sessions. They reported uneasiness discussing fear with students because it might lead to more fear. Instead, they relied on observing body language to infer the presence of fear. They attempted to allay fears with verbal distraction techniques.

Factors contributing to a chaotic vaccination clinic

Nurses reported they experience an element of unpredictability at school vaccination clinics. Confusion around allotted rooms, missing consent forms, and technological difficulties with vaccination recording software (Panorama™ in Ontario) contribute to a sense of chaos. Such issues contributed to difficulties in complying with schedules and strained interactions with school staff.

Parents and students felt that an insufficient number of reminders of vaccination dates were provided so that sometimes students would arrive at school not expecting to be vaccinated that day. E-mail reminders for parents, and in-class reminders by teachers and school nurses close to vaccination day, were suggested.

Outer setting

Social environment

Participants described the social milieu at schools on vaccination day as being fear-inducing. Often, one or a few students would express their feelings of anxiety, which would spread from student-to-student until it pervaded all students who were to be vaccinated. Some students stated they would try to hide their needle fear because they might be negatively judged by peers. Participants stated that sometimes the teachers’ negative remarks about vaccination would amplify distress. Some school staff commented that adults, in general, tend to minimize the problem of needle fear and pain, whereas for some students, vaccination can be traumatic. Despite these challenges, students reported that when peers had difficult vaccination experiences, they sought to comfort and assist.

Helping parents address student needs

Some parents felt they knew how to achieve optimal vaccination experiences for their child such as by modeling a calm attitude, discussing pain and fear management, and/or picking the appropriate location for their child to be vaccinated. Others wanted to know how to improve the experience. Some parents expressed reluctance about disclosing personal information about their children on school records, including whether or not their child was fearful about vaccinations.

Characteristics of individuals

Students

Students reported wanting adults to respect their fear of needles and to act with compassion and understanding. They appreciated being more in control of the process by participating in decisions like choosing: a) a distraction agent, b) privacy or not, c) a support person, d) watching the injection/be warned about the puncture, and e) which arm to use. They acknowledged that nervous friends could influence their own attitudes and fears. Students liked the current practice of having a ‘buddy’ to go to and from the vaccination clinic but wanted to be able to choose their buddy to prevent being paired with someone they dislike.

School staff

Teachers reported seeing their role as being a support to students. They described themselves as inadequately informed about vaccination, and pain and needle fear mitigation and do not feel capable of answering many of the students’ questions. They suggested, however, that if given the tools and role, they could assist. They highlighted their ability to help identify fearful students, apply topical anaesthetics, and assist with organizing and conducting the clinics.

Parents

Parents believed they have the primary role in selecting the suitable vaccination environment for their children. They reported nurses ought to make basic accommodations for students, but that children with complex needs should be vaccinated elsewhere. Parents stated that the quality of the school vaccination experience is important because it can influence their children’s feelings and attitudes about vaccinations in the future. Some parents acknowledged their own persisting fears about needles, and their attempts to hide them from their children.

There were mixed feelings about the current practice of having both parent and child sign the vaccination consent form. Some parents felt it was important to involve children in their own health care but others worried they might not be ready to make health decisions. Parents recognized their role in discussing immunization and coping with injections with their children. Some parents reported that they learned how to manage their child’s vaccination experience from experience with their firstborn children and used their insights with their younger children.

Injecting and school nurses

Nurses responsible for injecting vaccines at the school clinic are confident in their abilities to handle school vaccinations, including reducing student fear and pain. They consider some fear to be expected but that fear is exaggerated in some children. They feel capable of answering questions about immunization. School liaison nurses enjoy being involved on vaccination day and helping to support students while waiting to be vaccinated and during vaccination.

DISCUSSION

This study demonstrated that students, parents, school staff, and public health nurses accept the school as an appropriate setting for student vaccinations. However, they identify opportunities for improvement in the preparation of all stakeholder groups ahead of time, as well as for vaccination day processes and interactions.

These results are consistent with our prior work demonstrating that school vaccinations can be stressful for students and adults (2,3). In particular, there is inadequate education provided to students, parents, and school staff regarding what will happen and how to cope with pain and fear. There is inadequate consideration of the setting and process for conducting vaccinations on clinic day during the planning stages and insufficient and inconsistent involvement of adults (nurses and school staff) in supporting students.

Based on these findings, a multifaceted KT intervention is recommended that addresses the needs of all the stakeholders involved in school vaccinations at two time points: prior to vaccinations (i.e., preparation) and during vaccinations (i.e., utilization of coping strategies). Public health work processes need to be re-examined to look for opportunities to accommodate this recommendation. This includes more diligent and explicit documentation of planning steps ahead of time to ensure that appropriate spaces are available for vaccination (including access to privacy) and that students can use self-selected interventions during vaccinations (e.g., electronic devices, support person). Alterations to usual in-class student education are also required. Topics should include the rationale for vaccinations, the process for school vaccinations, and methods to mitigate pain, fear and fainting. The usual slide facilitated lecture-style lesson should be altered to include videos, pamphlets, and discussion/practice. Slides can be used for vaccine-specific information (e.g., antigens and injection schedules), which frequently changes from year to year. Education of teachers can be achieved via participation in the in-class student lessons, meetings with public health nurses and principals as well as via dissemination of written information. Parents can be provided with written information accompanying vaccination consent forms. On vaccination day, clinics can be organized to minimize fear, students can be triaged according to level of fear and special requests, and students can use their preferred coping strategies during vaccination. Clear role identification and participation is required for school nurses, injecting nurses, and school staff to ensure coordinated and complementary efforts.

To our knowledge, this is the first study to systematically target and elicit detailed feedback from all the relevant stakeholder groups involved in school vaccinations in a coordinated way. The results provide clear avenues for the creation of a multifaceted KT intervention as described above. Ensuring that participants from all relevant stakeholder groups are involved improves the likelihood that KT interventions that are developed will be relevant and usable. There are also some limitations that warrant discussion. First, we included only a few study sites and participants, and for parent stakeholder groups, we included only mothers, and it is possible that not all perspectives were identified. We did, however, include individuals with different experiences and perspectives and results were consistent with prior studies. Second, the findings may not reflect other geographical regions whereby the school vaccination program may differ. Prevaccine education elsewhere may include websites or teacher-led in-class lessons, rather than in-class lessons by public health nurses. Third, while we used CFIR to code participant perceptions, CFIR was originally developed to document the perceptions of implementers only (13). The views of other stakeholders (i.e., students, parents) were coded within the existing domains; however, it is recommended that future studies utilize inductive coding to capture the perceptions of nonimplementers.

In summary, we documented the needs and preferences of students, parents, school staff, and public health nurses in the Niagara region regarding the KT tools and processes to guide improvements in the school-based vaccination program. Continuing this line of research, the next two manuscripts in this series (14,15) describe the results of stakeholder feedback and pilot testing of tools included in a multifaceted KT intervention called The CARD™ System developed with input from the present study. The final two manuscripts in this series describe the impact of CARD™ when fully implemented in the school vaccination program in selected schools in a controlled clinical trial (16,17).

Funding information: This project was funded by the Canadian Institutes of Health Research Knowledge to Action Grant (KAL-147564).

Potential conflicts of interest: AT reports Section 9 Trademark No. 924835 for CARD. LMB reports that Immunize Canada received grants from Pfizer Canada, Merck Canada, GSK Canada, Seqirus Canada and Sanofi Pasteur outside the submitted work. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Pain Pain Go Away Team:

Angela Alfieri-Maiolo RN MPHN⁵, Lucie M. Bucci MA⁶, Christine Halpert RN MA⁷, Kate Robson⁸, Evelyn Wilson MAEd BPHE⁹, Jocelyn Cortes RN¹⁰, M. Mustafa Hirji MD MPH⁵, Melanie Badali PhD¹¹, Anthony N. T. Ilersich¹, Angelo L. T. Ilersich¹, Cathryn Schmidt², Srdjana Filipovic PhD²

¹Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario; ²The Hospital for Sick Children, Toronto, Ontario; ⁵Niagara Region Public Health & Emergency Services, Thorold, Ontario; ⁶Immunize Canada, Ottawa, Ontario; ⁷British Columbia Centre for Disease Control; ⁸Canadian Family Advisory Network; ⁹Ontario Institute for Studies in Education, University of Toronto; ¹⁰Ontario Ministry of Health and Long-Term Care; ¹¹AnxietyBC, Vancouver, British Columbia