Elsevier

Vaccine

Volume 29, Issue 52, 6 December 2011, Pages 9588-9599
Vaccine

Review
School-based vaccination: A systematic review of process evaluations

https://doi.org/10.1016/j.vaccine.2011.10.033Get rights and content

Abstract

Objective

School-based vaccination is becoming a more widely used method of vaccine delivery. However, evaluations of school-based vaccination program implementation have not been systematically reviewed. This paper describes the results of a systematic review of the literature on process (or implementation) evaluations of school-based vaccination delivery.

Methods

Search terms: “school based vaccination” OR ((“schools” OR “school”) AND (“immunisation” OR “immunization” OR “vaccination”)). Limits: Humans; English language; Age: 6–18 (school-age children and adolescents); No editorials; No letters. Databases: PUBMED; Embase.com; Cochrane Database of Systematic Reviews; Cinahl; Web of Science; PsycINFO. Inclusions: Articles must have originated from an advanced economic ‘developed’ country, be peer-reviewed, available in English, randomised or non-randomised controlled design, published from 1970 to August 2010 and focused on vaccinations provided in the school setting and during school time which reported one or more outcomes. Exclusions: qualitative or descriptive papers without any evaluation component; papers that only reported on impact evaluation (i.e. number of students vaccinated); and those published before 1970.

Results

A total of 14 articles were identified as including some element of a process evaluation of a school-based vaccination program. Nurses, parents, teachers, and adolescents were involved in measures of procedural factors related to school-based vaccination implementation. Outcomes included return rates of consent forms; knowledge about the specific vaccine offered; attitudes toward vaccination and school-based vaccination; reasons for non-vaccination; resources, support, and procedures related to implementation; and environmental factors within the school that may impact vaccination success. Vaccination coverage was also reported in the majority of papers.

Conclusions

Many studies reported on the importance of ensuring all stakeholders (school nurses, parents, teachers, and adolescents) receive appropriate information and are involved in the vaccination program and implementation processes. Specific consent form dissemination procedures have demonstrated higher return rates. Further controlled studies are needed to determine the best practice approach to implementing these programs is a variety of contexts.

Highlights

► Evaluations of school-based vaccination implementation have not been systematically reviewed. ► 14 articles included a process evaluation of a school-based vaccination program. ► Many studies cited the importance that all stakeholders are actively involved in the processes. ► Controlled studies are needed to ascertain best practice approaches for school-based programs.

Introduction

As more vaccines are being recommended for use in the adolescent age group, school-based vaccination is emerging as an increasingly common method of vaccine delivery [1], [2], [3]. A review of the evidence-base regarding the use of vaccination programs in schools and organised childcare centres to improve immunisation coverage concluded that there is strong evidence that such programs are effective in improving uptake among children and adolescents for a range of vaccines [4].

Voluntary school-based vaccination of adolescents has been successful in achieving high rates of vaccination against hepatitis B in Australia, Canada and Italy, among other European countries [5], [6], and more recently for HPV vaccination in the UK, Canada and Australia [7], [8], [9]. Mass voluntary school-based vaccination has been utilised in specific one-off (one-time only; non-routine) initiatives targeting a single disease in the United States with some success [10], [11], [12], [13], [14]. Prior to jurisdictional-wide school-based vaccination programs in Australia, coverage for recommended adolescent vaccines was low (18–30%), and commencement of these programs has more than doubled uptake [15], [16]. This method of vaccine delivery has been demonstrated to achieve high coverage in targeted populations, most likely because it removes several obstacles to vaccination that may exist in a model relying on primary care delivery, including cost of and access to both the vaccine and a primary care provider, as well as the time to take off work/school to travel and visit the provider. As adolescents have low physician attendance compared with other age groups, the opportunities to vaccinate are lower [17], [18]; this is especially so in countries that do not have routine, adolescent preventive health visits. In advanced economic countries, school attendance rates are high [19], and so schools are an ideal setting to capture the majority of the adolescent population for vaccination.

Coverage data from school-based vaccination programs often show marked differences across jurisdictions and geographical regions, as is the case in Australia [16], [21], [22], [23], though little is known about what factors promote higher uptake in individual schools or across jurisdictions. A better understanding of factors that may impact vaccine uptake in these programs would be of value in developing policy around school-based vaccination for countries considering this method of delivery, as well as enhancing delivery in countries where school-based vaccination is already established. Many countries are currently grappling with the most effective method of implementing adolescent vaccine recommendations, as this target group is outside the age range of traditional and well-established childhood vaccination programs, where effective processes are better understood [24]. Without effective processes for school-based vaccination, uptake will likely not come close to desired targets [25].

Most school-based vaccination stakeholders, including school personnel; immunisation nurses; public health professionals; adolescents; and parents, relate satisfaction with the school-based approach to vaccination. Identified points of satisfaction include convenience and the opportunity for peer support while being vaccinated [20]. In contrast, this same research identified a perceived burden on teachers overseeing the vaccination program, and procedural issues impacting on vaccination day efficiency [20].

A further challenge for these programs is the rapid spread of rumours in school-based settings. A shared social norm may be communicated through a group, causing an individual's perception of the threat to be distorted [26]. Evidence of both personal fear and collective distress to a perceived threat (or rumour) can lead to symptoms of anxiety. This anxiety may be low-level, causing distress without severe impact, yet it has also been observed to magnify, sometimes so much that mass psychogenic illness occurs [27], [28], [29], [30], [31].

To better determine which processes are important for optimal implementation of school-based vaccination programs, it is critical to understand the level of evidence currently available in this area. To determine this, a systematic review of the literature on process evaluations of school-based vaccination delivery, published between 1970 and August 2010 was undertaken.

Section snippets

Methods

Broadly, a process evaluation investigates through what means a program does or does not fulfil its aims [32], [33]. It is the component of program evaluation which examines how a program is implemented in order to monitor, improve or understand the strengths and weaknesses of the approaches taken. A program, as defined by the US Centres for Disease Control, may include, but is not limited to: media campaigns, service provision, educational services, public policies, and research projects.

Overview of all included studies

A total of fourteen articles were assessed to be process evaluations of school-based vaccination programs (see Table 1; studies listed in alphabetical order according to whether they were an intervention study or non-intervention study). The majority of research studies were conducted in the United States and are based on one-off (one time only, non-routine) vaccination programs, most often for Hepatitis B. Only five studies were conducted within the context of established, routine school-based

Discussion

There were no identified studies that evaluated different planning/logistical approaches to school-based vaccination delivery to determine the most effective approach. Also absent were studies that directly evaluated school-based delivery compared with another method of delivery. This is likely because such studies would be challenging to undertake in a setting where population-wide school-based immunisation programs already exist and may not be perceived as necessary when they are achieving

Conclusions

Despite the limited amount of evidence available to support best practice, suggestions for better practice can be made: suggestions can be drawn from the gaps in the evidence as well as from the lessons learned from the reviewed studies. Overall all stakeholders (school nurses, parents, teachers, and adolescents) indicated that they would like to be provided with appropriate information and involved in the planning and implementation process. Consent form return seems to be an issue of

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