Abstract
Objective
School-based vaccination programs can be a source of distress for many students due to the pain from the needle injection and related fears. We created a multifaceted Knowledge Translation (KT) intervention to address vaccination and pain, fear, and fainting called The CARD™ System. The objectives were to document acceptability of key tools included in the multifaceted KT intervention and their effectiveness in improving knowledge and attitudes about vaccination pain and fear.
Methods
Quantitative and qualitative methods were used. Students, school staff, public health nurses, and parents participated in separate focus groups whereby they independently completed a knowledge and attitudes survey and provided structured and qualitative feedback on key KT tools of the multifaceted KT intervention. They then repeated the knowledge and attitudes survey.
Results
Altogether, 22 students (grade 6 and 7), 16 school staff (principals, grade 7 and 8 teachers, resource teachers, secretaries), 10 nurses (injecting, charge, and school nurses), and 3 parents participated. Knowledge test scores increased post-KT tool review: 8.5 (2.1) versus 7.3 (1.9); P<0.001. Attitudes were more positive about the individual nature of pain and fear experience during vaccination. Student fear scores were lower post-tool review: 5.1 (2.9) versus 4.6 (3.0); P<0.001. The majority of the participants reported they understood all the information, the amount was just right and that the information was useful.
Discussion
The KT tools were demonstrated to be acceptable and to improve knowledge. Future research is warranted to determine their impact on student experience during school vaccinations.
Keywords: Knowledge Translation, Pain management, Vaccination
High vaccination coverage rates are an important goal for school-based vaccination programs to reduce the burden of vaccine-preventable disease in students and society and vaccine coverage in this population is routinely monitored (1). Student fear of needles and associated vaccine injection pain are common (2–5), and can produce a negative experience with school vaccinations by causing worrying ahead of time, higher pain during vaccination, and fainting (6). Negative student attitudes and experiences with vaccination can lead to vaccination hesitancy, future vaccine refusal, and suboptimal vaccine uptake rates (2).
In 2015, we developed a Clinical Practice Guideline (CPG) to address pain, fear, and fainting during vaccine injections (7). The guideline included tools to assist with uptake of the CPG recommendations (7); however, specific guidance for school-based vaccinations was lacking due to the dearth of research evidence for this vaccination setting. Using the Knowledge-to-Action (8) cycle and the Consolidated Framework for Implementation Research (CFIR) (9) to guide our work, selected authors of the CPG (7) partnered with organizations responsible for delivering vaccinations at school, including public health and school boards, to undertake a Knowledge Translation (KT) project to adapt the CPG (7) for the school setting. An outline of the project is provided in the first of a series of articles in this issue of Paediatrics & Child Health (10). In the second (overview) manuscript, we provide more information about the process used, key tools developed, and impact on student symptoms and other program delivery outcomes (11).
Studies report on the importance of including all stakeholders, including students, nurses, school staff, and parents, in the vaccination program to ensure optimal implementation processes (12). To this end, we explored the local barriers and facilitators to CPG (7) uptake at school with all the stakeholders (13). From key themes, we developed a multifaceted KT intervention called The CARD™ System (C–Comfort, A–Ask, R–Relax, D–Distract). CARD provides a framework for planning and delivering vaccinations at school that utilizes a student-centred approach. Importantly, CARD™ addresses two main identified student educational needs—procedural preparation and pain, fear, and fainting management—and engages students as active participants in their health care. In the present paper, we provide preliminary evidence from both quantitative and qualitative approaches for the acceptability of key tools of The CARD™ System and impact on knowledge and attitudes about pain and fear.
METHODS
Participants and setting
Participants included a convenience sample of students, parents, school staff, and public health nurses from two urban settings in Ontario—Niagara and Toronto. As students in Ontario undergo vaccination in grade 7, we specifically targeted students in grades 6 and 7 to capture those with and without prior experience with school vaccinations. Parents of children of any age were included. Only school staff and nurses with experience with school vaccinations were eligible.
Settings for recruitment were identified in collaboration with the participating local public health units, school boards, and the Canadian Family Advisory Network (CFAN), a patient advocacy group and partner on this project. Students, school staff, and parents from a total of seven schools and nurses from one public health unit participated. Schools were of varying sizes and type including public nondenominational, public Catholic and independent. Eligible students, school staff, and parents were invited to participate by the school principal. Public health nurses were invited by a local public health unit manager. All participants signed a consent form. Parents also provided consent for children. The study was approved by the Research Ethics Boards of the University of Toronto and the relevant school boards [Toronto District School Board (TDSB) and the Niagara Catholic District School Board (NCDSB)].
The sample size was set at 3 to 12 individuals per focus group for school staff, nurses and parents; for students, it was 3 to 50 to allow for entire classes to participate. Focus groups were held on up to four separate occasions per stakeholder group to facilitate participant attendance. Students, parents, and school staff participated at their respective schools. Nurses participated at their local public health headquarters.
Materials and procedure
We used both qualitative and quantitative methods, similar to our prior work with development and testing of KT interventions directed to new parents and clinicians (14,15). Briefly, each user group participated in a separate session consisting of three parts: 1) presurvey; 2) focus group discussion regarding key tools of the multifaceted KT intervention (two videos and selected pamphlets); and 3) postsurvey.
Before the focus group, all participants independently completed a knowledge and attitudes survey about vaccination pain and fear perception. The knowledge component included 10 yes/no questions about the effectiveness of different strategies to reduce pain, fear and fainting (see Appendix 2 from overview paper in this series for questions) (11) and was specifically developed for this study primarily based on content from the CPG (7). The attitudes component included statements about pain and fear that participants rated their level of agreement with using a five-point Likert scale: ‘Vaccine injections cause the same amount of pain in everybody’; and ‘Vaccine injections cause the same amount of fear in everybody’. Students additionally answered the question ‘How afraid are you of vaccination needles?’ on a scale of 0 (no fear) to 10 (worst possible fear).
During the focus group discussion component, each stakeholder group then reviewed key tools of the multifaceted KT intervention created to address the previously identified informational needs (13). Participants answered structured questions about whether they understood the information and the adequacy of the quantity of information; they answered open-ended questions about information to add or to remove and implementation considerations (see Appendix 1 from overview paper in this series for the questions) (11). They supplemented written feedback with oral feedback and discussion.
Participants first viewed a video (https://youtu.be/ z57vTpb19wQ) (duration, 4 minutes) that instructs students about vaccinations and includes information about what a vaccine is and how it works, side effects of vaccines, and the process for school-based vaccinations, including consent and information about what will happen on the day of vaccination. Then they viewed a video (https://youtu.be/c41HvgEKQSk) (duration, 7 minutes) that instructs students in a mnemonic (‘The CARD™ System’ whereby C–Comfort, A–Ask, R–Relax, D–Distract) about how to reduce pain, fear, and fainting during vaccination and includes vignettes of students undergoing vaccination using the strategies included in the mnemonic.
Three companion pamphlets were prepared for students, parents, and school staff respectively, that included different elements from the videos (see Figures 2 to 4 in overview paper in this series for the pamphlets) (11). The student pamphlet includes fill-in-the-blank spaces for each letter of CARD™ whereby students can record strategies they plan to use for upcoming vaccinations. Parent and school staff pamphlets both included information about vaccination and CARD™. The student pamphlet was reviewed by all stakeholder groups. The parent pamphlet was reviewed by parents, school staff, and public health nurse groups. The school staff pamphlet was reviewed by school staff and public health nurse groups.
Participants also provided basic demographic information including: age, sex, and position (school staff and nurses only). In the last part of the session (i.e., following review and feedback about the tools), participants repeated the knowledge and attitude survey described previously.
Analytic strategy
Quantitative data were analyzed using descriptive statistics (i.e., central tendency and variability). Pre- and post-tool knowledge test scores (number of correct answers summed for a total score out of 10), responses to attitude statements, and pre- and post-fear levels (students only) were compared using a series of paired samples t-tests. The statistical program SPSS (version 24) was used to analyze the data. A P-value of <0.05 was considered significant. Audiotapes of interviews were transcribed verbatim. All qualitative results (oral and written) were analyzed using directed content analysis (16) using CFIR (9). Three authors participated in the qualitative analysis; one coded the data and two reviewed the codes against the transcripts. Disagreements were resolved by consensus.
RESULTS
The study was conducted between May 23, 2017 and December 14, 2017. Altogether, two sets of data collection/focus groups were conducted with students (n=22), four sets with school staff (n=16), one with public health nurses (n=10), and one with parents (n=3). Demographic characteristics are shown in Table 1.
Table 1.
Demographic characteristics of participants
| Age in years | Female sex | |
|---|---|---|
| Students (n=22)a | 11.8 (0.8)* | 16 (72.7) |
| School staff (n=16)b | 44.5 (6.4)** | 10 (66.7)** |
| Public health nurses (n=10)c | 35 (11.5)*** | 10 (100) |
| Parents (n=3) | 48.7 (5.0) | 2 (66.7) |
Values are mean (standard deviation) or frequency (percent).
an=8 grade 7; n=14 grade 6.
bn=9 teachers, n=4 principals, n=2 resource teachers, n=1 administrative staff.
cn=8 injecting and charge nurses; n=2 school nurses.
*n=21; **n=15; ***n=6.
Quantitative data
Feedback regarding acceptability of the KT tools is shown in Table 2. Most participants reported they understood the information in the videos and pamphlets, and that the amount was just right. The mean (standard deviation [SD]) knowledge test scores were higher post-tool review compared to baseline (Table 3). Participants’ attitudes about the individual nature of pain and fear improved (Table 4). Student fear scores were lower post-tool review compared to baseline: 5.1 (2.9) versus 4.6 (3.0); P<0.001.
Table 2.
Structured feedback for Knowledge Translation (KT) tools
| Student* | School Staff | Nurses | Parents** | |
|---|---|---|---|---|
| Video 1 (Information about getting a vaccination at school) | ||||
| Understood most or all information | (n=20) 19 (95) |
(n=10) 10 (100) |
(n=9) 9 (100) |
(n=3) 3 (100) |
| Amount of information “just right” | (n=20) 19 (95) |
(n=11) 11 (100) |
(n=10) 10 (100) |
(n=3) 2 (66.7) |
| Video 2 (Information about The CARD™ System) | ||||
| Understood most or all information | (n=21) 20 (95) |
(n=13) 13 (100) |
(n=9) 9 (100) |
(n=2) 2 (100) |
| Amount of information “just right” | (n=21) 16 (76) |
(n=14) 11 (79) |
(n=10) 10 (100) |
(n=3) 2 (66.7) |
| Student pamphlet (Information about The CARD™ System) | ||||
| Understood most or all information | (n=17) 16 (94) |
(n=13) 13 (100) |
(n=10) 10 (100) |
(n=2) 2 (100) |
| Amount of information “just right” | (n=17) 16 (94) |
(n=14) 14 (100) |
(n=9) 9 (100) |
(n=3) 3 (100) |
| Parent pamphlet (Information about vaccination and The CARD™ System) | ||||
| Understood most or all information | - | (n=6) 6 (100) |
(n=10) 10 (100) |
(n=2) 2 (100) |
| Amount of information “just right” | - | (n=6) 6 (100) |
(n=9) 9 (100) |
(n=3) 3 (100) |
| School staff pamphlet (Information about vaccination and The CARD™ System) | ||||
| Understood most or all information | - | (n=5) 5 (100) |
(n=10) 10 (100) |
- |
| Amount of information “just right” | - | (n=5) 5 (100) |
(n=10) 10 (100) |
- |
Values are frequency (percent).
*Students did not review the parent or school staff pamphlet.
**Parents did not review the school staff pamphlet.
Table 3.
Knowledge test scores
| Baseline | Post-tool review | |
|---|---|---|
| Students (n=22) | 6.0 (1.7) | 6.8 (2.1) |
| School staff (n=16) | 7.8 (1.8) | 9.6 (1.1) |
| Public health nurses (n=10) | 9.1 (0.3) | 10.0 (0) |
| Parents (n=3) | 8.0 (1.0) | 9.3 (1.1) |
| Total (n=51) | 7.3 (1.9)* | 8.5 (2.1)* |
Values are mean (standard deviation); range of scores 0 to 10.
*Paired t-test: P<0.001.
Table 4.
Attitudes about pain and fear
| Vaccine injections cause the same amount of pain in everybody. | Vaccine injections cause the same amount of fear in everybody. | |||
|---|---|---|---|---|
| Baseline | Post-tool review | Baseline | Post-tool review | |
| Students (n=22) | 3.7 (0.6) | 4.2 (0.8) | 3.9 (0.7) | 4.2 (0.8) |
| School staff (n=16) | 3.7 (0.9) | 4.5 (0.5) | 4.4 (0.5) | 4.5 (0.5) |
| Public health nurses (n=10) | 4.4 (0.5) | 4.8 (0.4) | 4.7 (0.5) | 4.8 (0.4) |
| Parents (n=3) | 4.0 (0) | 4.7 (0.6) | 4.0 (0) | 4.7 (0.6) |
| Total (n=51) | 3.8 (0.8)* | 4.3 (0.7)* | 4.2 (0.6)** | 4.5 (0.6)** |
Values are mean (standard deviation); scores range from 1 to 5 (strongly agree, agree, no opinion, disagree, strongly disagree).
*Paired t-test: P<0.001; **Paired t-test: P=0.01.
Qualitative data
The qualitative feedback fit into two of the five domains of CFIR (9): 1) intervention characteristics and 2) inner setting (i.e., characteristics of the environment/organization in which the interventions are employed).
Intervention characteristics
Participants from all stakeholder groups said they learned from the KT tools. Child #1: “I learned about community immunity, never heard about it before, made me feel responsible….I learned that everyone feels pain differently and we can manage it through the CARD system.” Most participants reported on the simplicity with which information was presented. Child #12: “Very easy. It is organized nicely, it is easy to follow.” A few participants commented that there was too much information in the videos and too many needles. One suggested solution was reviewing the information over a couple of days. Other participants however, wanted additional information about specific interventions (e.g., topical anaesthetics). Participants appreciated the consistency in language because it could facilitate communication and collaboration among all stakeholders. Nurse #4: “Great that teachers and parents and school nurses can help prepare with (the) CARD concept ahead of time.” Participants also expressed approval of the inclusion of a peer narrator and authentic student vaccination experiences and testimonials. Teacher #2: “I like the way that it was a child that was talking about it, so the kids can relate more to it, and that they got to express what they were thinking…”
Inner setting
Participants considered the KT tools to be compatible with current education and health care delivery approaches (e.g., patient-centred care) which call for student involvement. Nurse #3: “Empowering students. Giving them tools for coping.” Nurse #8: “…student focused.” Some participants expressed considerable enthusiasm about using them for future vaccinations. Nurse #4: “…The CARD concept is fabulous, I can’t wait to utilize this new technique.” Teachers spoke about the utility of the CARD™ concept beyond pain. Teacher #4: I can use this for things like big tests coming up or major assignments…if I sense a lot of anxiety…” Suggestions for how to use the videos and student pamphlet included incorporating them into school classroom lessons prior to school vaccinations and reviewing the information on vaccination day. Posting the information in a variety of settings including classrooms, waiting rooms, and on websites was also recommended. Some participants suggested supplementing the KT tools with mock classroom demonstrations/practice and reminders. Adult participants expressed working collaboratively to support students. Parent #2: “Absolutely, and reinforcing it at home as well as at school, so to me I personally think that tag teaming with the teachers and principal bringing forward the information at school but also having backed up at home as well…”
Minor edits that were made to the videos and pamphlet to incorporate feedback (e.g., loudness of background music was reduced in the videos, minor changes in wording were made in pamphlets) have been incorporated in the tools (11).
DISCUSSION
Despite the high prevalence of pain and fear in students undergoing vaccinations at school (2–5), there is a paucity of research examining approaches to improve the school vaccination experience (17). Students, vaccinating nurses, school staff, and parents have reported being un-informed and ill-equipped to minimize student fear and pain during school vaccinations (3–5,13). Negative attitudes and experiences with vaccinations can lead to vaccine refusals by students (6) and contribute to individual and population morbidity from vaccine-preventable disease.
Medical information provision is highly recommended to help prepare children for upcoming medical procedures (18,19). Appropriate preparation aims to offer realistic expectations about a procedure, build trust, provide some perception of control, and foster self-efficacy with coping (18). For information to effectively influence a student’s perceptions and coping behaviour, however, it must be valued, understood, specific, and packaged in an engaging manner. Guided by the feedback of students, school staff, nurses and parents (13) and theories about medical procedure information provision in children (18), we created 2 videos narrated by a peer model and a worksheet (student pamphlet) as the key KT tools for student procedural preparation. We also created companion parent- and school staff-specific pamphlets. In the current study, all stakeholder groups provided feedback on the two videos and the student-directed pamphlet. Parents additionally provided feedback about the pamphlet directed to parents, and school staff and nurses additionally provided feedback about the pamphlet directed to school staff.
Preliminary evidence for the effectiveness of the KT tools was demonstrated by an increase in knowledge about effective pain, fear and fainting interventions, as well as more positive attitudes about the individual nature of pain and fear experience during vaccination. In addition, student fear about vaccination needles was significantly diminished after tool review which supports the effectiveness of the intervention in providing appropriate preparation for school-based vaccinations. More specifically, this reduced fear likely reflects more realistic appraisals of the procedure, enhanced self-efficacy, and greater perceptions of control given the individualized nature of the CARD™ tool which encourages active behavioural and cognitive coping (18,20). Acceptability of the KT tools was demonstrated by high ratings for understandability and adequacy of quantity of information, and positive feedback regarding design qualities and compatability of the KT tools with current education and health care delivery approaches.
Our results are consistent with a study that implemented an educational event about vaccinations in child recreational facilities in Japan (21). In that study, 194 children aged 7 to 9 years learned about different needle procedures, how a vaccine works, and then ‘injected a vaccine’ (i.e., injected water into a sponge) in a 1-hour training session facilitated by medical or nursing students. Self-assessment surveys documented a posteducation reduction in fear of needles and increase in willingness to be vaccinated in the future.
There are several strengths of this study. First, we used a rigorous and comprehensive approach to KT tool evaluation, involving both quantitative and qualitative aspects. Second, we included participants from all relevant stakeholder groups. The school vaccination context involves a complex system involving interplay between students, nurses, school staff, and parents. Including all groups improves the likelihood that KT interventions will be relevant and usable. There are several limitations that can guide future research efforts. First, we included only a few study sites and participants, and it is possible that not all perspectives were identified. Given that the KT tools were developed with stakeholder group input (13) suggests that this is not a major issue. Second, we evaluated knowledge acquisition and attitudes in close temporal proximity to the intervention. It is not known if this translates to better vaccination experiences in the future. Importantly, the optimal timing for the education relative to school vaccinations and the need for discussion and/or reinforcement and practice cannot be discerned from the present study; this is a common issue with much of the procedural preparation/education literature and remains an area for future research (18,22). Third, the KT tools do not address the needs of subgroups of students, such as those with high levels of needle fear, who may benefit from more intensive interventions, such as exposure-based therapy (23). Investigating whether the needs of boys versus girls or individuals of various cultural/ethnic backgrounds differ and require tailoring of the KT tools is also warranted. Fourth, while we used a theoretical model (i.e., CFIR) to code qualitative data, CFIR was originally developed to document the perceptions of implementers only (9). We recommend that future studies capture the specific perceptions of other stakeholders using an inductive approach.
In summary, we documented preliminary acceptability and effectiveness of KT tools about pain, fear and fainting on conceptual knowledge and attitudes about pain and fear. In other articles in this series, we report the impact on student and other stakeholder experiences with school vaccinations when these KT tools were implemented at school using diverse approaches (24–26).
ACKNOWLEDGEMENTS
The authors thank the individuals who participated in this project. We also thank staff at the public health units and schools for their commitment to improving the quality of care provided at their respective organizations.
Funding: 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:
Evelyn Wilson MAEd BPHE6, Kate Robson7, Srdjana Filipovic PhD2, Cathryn Schmidt2, Christene deVlaming-Kot RN MHSc5, Leslie Alderman RN5, Angela Alfieri-Maiolo RN MPHN5, Lucie M Bucci BA8, Christine Halpert RN MA9, Jocelyn Cortes RN10, Melanie Badali PhD11, M. Mustafa Hirji MD MPH5.
2The Hospital for Sick Children, Toronto, Ontario; 5Niagara Region Public Health & Emergency Services, Thorold, Ontario; 6Ontario Institute for Studies in Education, University of Toronto; 7Canadian Family Advisory Network; 8Immunize Canada, Ottawa, Ontario; 9British Columbia Centre for Disease Control; 10Ontario Ministry of Health and Long-Term Care; 11AnxietyBC, Vancouver, British Columbia
Contributor Information
Pain Pain Go Away Team:
Evelyn Wilson, Kate Robson, Srdjana Filipovic, Cathryn Schmidt, Christene deVlaming-Kot, Leslie Alderman, Angela Alfieri-Maiolo, Lucie M Bucci, Christine Halpert, Jocelyn Cortes, Melanie Badali, and M Mustafa Hirji
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