The CARD™ System for improving the vaccination experience at school: Results of a small-scale implementation project on program delivery

Enhancing HPV vaccine uptake in girls and boys - A qualitative analysis of Canadian school-based vaccination programs

The purpose of this study was to better understand barriers and enabling conditions for HPV vaccination in school-based vaccination programs in Canada. Semi-structured interviews were conducted by telephone or in person with parents, nurses, and school staff (n = 50) in three Canadian provinces. Interviews explored views on HPV and HPV vaccination, strengths and weaknesses of the school-based HPV vaccination programs and proposed interventions to increase uptake. Interview transcripts were coded and analyzed thematically using the socio-ecological model. Participants had positive views towards HPV vaccination and school-based offer. They identified barriers and enabling conditions at the individual and interpersonal level (e.g., knowledge, attitudes, behaviours of - and relationships between - parents, nurses, and school personnel), at the organizational level (e.g., allocated resources, information provision, process to ensure informed consent, vaccination setting and environment) and at the community and policy level (e.g., social group values and norms, media coverage around the HPV vaccine). Participants also suggested strategies to reduce identified barriers (e.g., communication interventions, simpler inform consent process). Different layers of barriers and enabling conditions of HPV vaccination in school settings were identified. Tailored interventions remain key to enhance vaccine acceptance and uptake.

CARD (Comfort Ask Relax Distract) for school-based immunizations in Calgary, Canada: a pragmatic cluster trial

ABSTRACT

School-based immunizations are fear-inducing events for many students and contribute to vaccine hesitancy. We developed an immunization delivery framework called the CARD (Comfort Ask Relax Distract) system that incorporates evidence-based interventions to improve the experience (eg, reduce fear, pain, dizziness). We evaluated CARD in grades 6 and 9 students in Calgary, Canada. In this pragmatic, hybrid, effectiveness-implementation, cluster trial, we randomized 8 Community Health Centres providing regional immunization services to CARD or control (usual care). In the CARD group, public health staff educated students about CARD and planned processes to reduce fear cues and support student coping choices during immunization. Students self-reported fear, pain, and dizziness during immunization using a 0-10 numerical rating scale; staff recorded procedure details, including vaccines administered, fainting episodes, and coping strategies used. Staff participated in focus groups afterward. Altogether, 8839 children from 105 schools in the 2019 to 2020 school calendar year were included. Fear was lower for CARD (mean = 3.6 [SD = 3.1] vs control 4.1 [3.2]; mean difference = -0.5; 95% confidence interval = -0.74 to -0.21; P < 0.001). Effectiveness persisted after stratification by student gender (male and female) and grade level (grade 6 and grade 9). Other symptoms did not differ. Compared with control, CARD students used peers, privacy, muscle tension, and topical anesthetics more; verbal distraction, deep breathing, and adult support were used less frequently ( P < 0.05, all analyses). Immunization rate did not differ. Staff reported positive to neutral attitudes about CARD. In summary, this pragmatic trial demonstrated that CARD improved the immunization experiences of students at school.

Prevalence of pain and fear as barriers to vaccination in children - Systematic review and meta-analysis

BACKGROUND

Injection-related pain and fear are common adverse reactions in children undergoing vaccination and influence vaccine acceptance. Despite the large body of literature on sources of vaccine non-compliance, there is no estimate of the prevalence of pain and fear as contributing factors. The objective was to estimate the prevalence of injection pain or fear of needles as barriers to childhood (i.e., 0-18 years) vaccination.

METHODS

Four databases were searched from inception for relevant English and French articles until August 2021. In addition, the references of recent systematic reviews and all articles included in the review were hand searched. Article screening and data extractions were performed in duplicate. Studies were included if they reported on injection-related pain or fear of needles in children (0-18 years) using a checklist/closed-ended question(s). Results were stratified by respondent (parents or children), type of pediatric population (general or under-vaccinated), and relative importance of barrier (pain or needle fear as primary reason or any reason for under-vaccination). Prevalence rates of pain or needle fear were combined using a random effects model. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist for prevalence data. Quality across studies was assessed using GRADE.

RESULTS

There were 26 studies with 45 prevalence estimates published between 1995 and 2021. For parent reports (of children) and children self-reported reasons for non-compliance, prevalence rates of pain or needle fear ranged from 5 to 13% in a general population and 8 to 28% in an under-vaccinated population, with a substantial variation in the prevalence estimates. There was no difference between category of respondent or relative importance on pain or needle fear prevalence rate. A regression model demonstrated an overall prevalence rate of pain or needle fear as an obstacle to vaccination of 8% in the general population and 18.3% in the under-vaccinated population. All evidence was very low in quality.

CONCLUSION

This is the first review to systematically quantify the prevalence and therefore, importance, of pain and needle fear as obstacles to vaccination in children around the world. Pain from injection or fear of needles were demonstrated to be sufficiently prevalent as barriers to vaccination in children to warrant attention. Addressing pain and fear has the potential to significantly improve vaccination acceptance.

Children's Perceptions of Dental Experiences and Ways to Improve Them

This qualitative study explored children's perceptions of their dental experiences and their acceptability of the CARD™ (Comfort, Ask, Relax, Distract) system, adapted for the dental setting as a means to mitigate dental fear and anxiety (DFA). A purposive sample of 12 participants (7 males) aged 8-12 years receiving dental care at the Paediatric Dental Clinic, University of Toronto, was recruited. Virtual one-on-one interviews were augmented with visual aids. Participants were oriented to and asked about their perceptions of various dental procedures. Data were deductively analyzed, according to the Person-Centered Care framework (PCC). Four themes were identified: establishing a therapeutic relationship, shared power and responsibility, getting to know the person and empowering the person. Children emphasized the importance of clinic staff attributes and communication skills. They expressed a desire to engage more actively in their own care and highlighted the positive influence of pre-operative education and preparation. Participants found the CARD™ system to facilitate opportunities for self-advocacy in their dental care.

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

Many people have negative experiences with vaccination due to stress-related reactions including fear and pain. We used a pre-post study design to evaluate the impact of implementing a modified version of the CARD (Comfort-Ask-Relax-Distract) system on stress-related reactions in individuals aged 12 y or older undergoing COVID-19 vaccinations in mass vaccination clinics. Vaccine recipients reported their level of pain, fear and dizziness during vaccination. Clinic staff reported their attitudes about CARD and use of CARD interventions. CARD improved client symptoms across genders and ages with an average reduction in needle pain, fear and dizziness of 75%, 40% and 44%, respectively. CARD was more effective in younger individuals. Clinic staff reported positive attitudes about CARD and uptake of selected CARD interventions. In summary, the modified CARD system reduced stress-related responses in a general population undergoing COVID-19 vaccinations in a mass vaccination clinic, was feasible and acceptable to staff. Future implementation efforts are recommended that include more diverse cultural contexts and incorporate education of individuals about CARD ahead of time.

Impact of the CARD (Comfort Ask Relax Distract) system on school-based vaccinations: A cluster randomized trial

BACKGROUND

The CARD (Comfort Ask Relax Distract) system is a vaccine delivery framework that integrates evidence-based interventions to reduce stress-related responses and improve the vaccination experience for children undergoing vaccinations at school. In preliminary studies, CARD was acceptable and effective. The objective was to evaluate CARD in a large, pragmatic trial to confirm its effectiveness in real-world settings.

METHODS

Hybrid effectiveness-implementation cluster randomized trial in schools receiving vaccination services from Wellington-Dufferin-Guelph Public Health. Forty schools with grade 7 students (12 years old) were randomized to CARD and control (n = 20/group). Nurses in CARD schools planned clinics with principals and educated students about CARD ahead of time. Principals disseminated information to staff and parents and sent reminders. Vaccination day processes minimized fear and facilitated student self-selected coping strategies. Nurses in control schools followed usual practices, which excluded principal meetings, education, reminders, and systematic integration of fear-reducing or child-selected coping strategies. Outcomes included stress-related symptoms (fear - primary outcome, pain, dizziness, fainting, post-vaccination reactions), use of coping interventions, vaccination uptake, attitudes and implementation outcomes (acceptability, appropriateness, feasibility, fidelity).

RESULTS

Altogether, 1919 students were included. Fear and pain were lower in CARD schools: OR 0.65 (95% CI 0.47-0.90) and OR 0.62 (95% CI 0.50-0.77), respectively. No students fainted in CARD schools compared to 0.8% in control (p = 0.02). Dizziness and post-vaccination reactions did not differ. Student-led coping interventions were used more frequently in CARD schools. Vaccination uptake was 76.1% in CARD schools and 72.5% in control schools (OR 1.13 (95% CI 0.85-1.50)). Staff and students had positive attitudes about CARD and implementation outcomes; however, recommendations were made to improve fidelity.

DISCUSSION

CARD reduced stress-related responses in students undergoing vaccinations at school and was positively received by students and public health staff. CARD is recommended to improve the quality of vaccination delivery services.

TRIAL REGISTRATION

NCT03966300.

Exploring key elements of approaches that support childrens' preferences during painful and stressful medical procedures: A scoping review

PROBLEM

Children undergoing medical procedures can experience pain and distress. While numerous interventions exist to mitigate pain and distress, the ability to individualize the intervention to suit the needs and preferences of individual children is emerging as an important aspect of providing family-centered care and shared decision making. To date, the approaches for supporting children to express their preferences have not been systematically identified and described. A scoping review was conducted to identify such approaches and to describe the elements that are included in them.

ELIGIBILITY CRITERIA

Studies that (a) described approaches with the aim to support children to express their coping preferences during medical procedures; (b) included the option for children to choose coping interventions; (c) included a child (1--18 years).

SAMPLE

Searches were conducted in December 2019 and November 2020 in the following databases: Cinahl, Embase, PubMed and Psycinfo.

RESULTS

Thirteen studies were identified that included six distinct approaches. Four important key elements were identified: 1) Aid to express preferences or choice, 2) Information Provision, 3) Assessment of feelings/emotions, 4) Feedback/Reflection and Reward.

CONCLUSIONS

Identified approaches incorporate components of shared decision-making to support children in expressing their preferences during medical procedures and treatments.

IMPLICATIONS

Children undergoing medical procedures can be supported in expressing their coping needs and preferences by using components of shared decision-making.

The Children's Action-Reaction Assessment Tool (CARAT) as an observational technique for assessing symptom management: An initial validation study with children aged 3-7 years undergoing needle procedures

PURPOSE

For many children, needle procedures are fearful events that are often painful. The first step in symptom management is to assess the child's pain and fear, and the next step is to use coping strategies to provide symptom relief for children who experience or feel pain and fear during procedures. The Children's Action-Reaction Assessment Tool (CARAT) is built on action-reaction strategies. This study aimed to determine the inter-rater reliability of the CARAT when used during needle procedures with 3- to 7-year-old children. DESIGN AND METHODS: We used a quantitative approach in which 21 children were observed by two independent observers during needle procedures to evaluate the inter-rater reliability of the CARAT. Data were analysed with descriptive statistics, and the observation scores were calculated with an intraclass correlation coefficient (ICC) test on SPSS for Windows, version 25.

RESULTS

The completed CARAT indicated the use of action-reaction strategies. Neither action nor reaction strategies were frequently used. The parents were seldom involved in the procedure. The inter-rater reliability showed a sufficient correlation between the observers. PRACTICE IMPLICATIONS: This study showed promising results for the inter-rater reliability of the CARAT, which can be used to facilitate care for children. The observational tool can be used to assess the use of action-reaction strategies in conjunction with needle procedures in children aged 3-7 years.

Preparing for a School-Located COVID-19 Vaccination Clinic

School-located vaccination events (SLVE) have a long history in the United States and have successfully contributed to lower morbidity and mortality due to vaccine-preventable diseases. The school is an ideal place to reach children from all cultures, socioeconomic groups, and age-groups and is conveniently situated in communities for ease of accessibility for students, parents, and staff alike. School nurses play an important role in planning for SLVE and are ideally positioned to initiate this process and provide accurate information, dispelling myths about vaccines. Because school nurses are considered a trusted source of health information by the school community, they can provide valuable education on the impact of vaccination on student and staff attendance. Conducting a successful SLVE requires research, planning, and partnerships, and these partnerships are needed both within the school setting and outside this setting, within the community at large. The proliferation of the current COVID-19 pandemic and the subsequent vaccine production has caused school nurses to take the lead in preparing for mass vaccination clinics in order to help mitigate this serious public health threat. This manuscript describes the process a group of school nurses used to develop SLVE plans in response to a pandemic.

Feasibility of implementation of CARD™ for school-based immunizations in Calgary, Alberta: a cluster trial

Background

Negative experiences with school-based immunizations can contribute to vaccine hesitancy in youth and adulthood. We developed an evidence-based, multifaceted and customizable intervention to improve the immunization experience at school called the CARD™ (C-Comfort, A-Ask, R-Relax, D-Distract) system. We evaluated the feasibility of CARD™ implementation for school-based immunizations in Calgary, Canada.

Methods

In a mixed methods study, two Community Health Centres providing immunization services, including 5 schools each with grade 9 students (aged approximately 14 years), were randomized to CARD™ or control (usual care). In the CARD™ group, public health staff and students were educated about coping strategies prior to immunization clinics. Clinics were organized to reduce fear and to support student’s choices for coping strategies. Public health staff in the CARD™ group participated in a focus group discussion afterwards. We sought a recruitment rate of 80% for eligible schools, an external stakeholder focus group (e.g., school staff) with 6 or more individuals, 85% of individual injection-related data acquisition (student and immunizer surveys), and 80% absolute agreement between raters for a subset of data that were double-coded. Across focus groups, we examined perceptions of acceptability, appropriateness, feasibility and fidelity of CARD™.

Results

Nine (90%) of eligible schools participated. Of 219 students immunized, injection-related student and immunizer data forms were acquired for 195 (89.0%) and 196 (89.5%), respectively. Reliability of data collection was high. Fifteen public health and 5 school staff participated in separate focus groups. Overall, attitudes towards CARD™ were positive and compliance with individual components of CARD™ was high. Public health staff expressed skepticism regarding the value of student participation in the CARD™ system. Suggestions were made regarding processes to refine implementation.

Conclusion

While most outcome criteria were satisfied and overall perceptions of implementation outcomes were positive, some important challenges and opportunities were identified. Feedback is being used to inform a large cluster trial that will evaluate the impact of CARD™ during school-based immunizations.

Trial registration

The trial is registered at ClinicalTrials.gov (NCT03948633); Submitted April 24, 2019.

Managing pain and fear: Playing your CARDs to improve the vaccination experience

Most vaccinations are administered with a needle, which can cause pain and pain-related symptoms such as fear and fainting. At present, interventions aimed at preventing pain and associated symptoms are not systematically integrated in the vaccination delivery process even though they contribute to negative experiences with vaccination and vaccination noncompliance. In this article, a novel framework for vaccination delivery called the CARD™ system was reviewed. CARD is an acronym for Comfort, Ask, Relax and Distract, whereby each letter category incorporates evidence-based interventions to reduce pain and fear and related symptoms. CARD can be integrated in usual vaccination planning and delivery activities in many settings to improve the vaccination experience and decrease pain and fear as barriers to vaccination. Immunizers in all settings and organizational leaders are invited to review their vaccination services against CARD to identify opportunities for enhancing the quality of care being provided.

Benchmarking public health pain management practices during school immunizations

Background

Pain and fear during immunizations can affect children and their future behaviour toward immunization. These negative experiences can be amplified when children receive vaccines as part of school-based immunization programs, where parental or tutor supports are missing. In 2015, HELPinKIDS&ADULTS, a Canadian network of experts, published a clinical practice guideline (CPG) on the management of pain and fear during immunization. This guideline has been endorsed by international, national and provincial organizations. However, the level of integration and implementation of the CPG into local and community immunization programs such as school-based immunization clinics is unclear.

Methods

An investigation whether public health units in Ontario integrated and implemented the pain and fear interventions recommended by the CPG into school-based immunization policies and practices was concluded.

Results

The study shows that the majority of public health units do have pain and fear policies and procedures in place, but interventions are not integrated in a consistent and formal manner, leading to suboptimal uptake of interventions during immunizations at school.

Conclusion

For pain interventions to be applied with sufficient fidelity and in enough individuals to have a meaningful effect, organizational leaders need to create directives and procedures that support implementation in a systematic and accountable manner.

Student Feedback to Tailor the CARD™ System for Improving the Immunization Experience at School

Increasing the comfort of vaccine delivery at school is needed to improve the immunization experience for students. We created the CARD™ (C-Comfort, A-Ask, R-Relax and D-Distract) system to address this clinical care gap. Originally designed for grade 7 students, this study examined the perceptions of grade 9 students of CARD™. Grade 9 students who had experience with school-based immunizations, either as recipients or onlookers (n = 7; 100% females 14 years old) participated. Students answered pre-post surveys, reviewed CARD™ educational materials and participated in a semi-structured focus group discussion. The Consolidated Framework for Implementation Research (CFIR) was used as the framework for analysis of qualitative data. Participants reported positive perceptions of CARD™ educational materials and that CARD™ could fit into the school immunization process. CARD™ improved knowledge about effective coping interventions and was recommended for education of both nurses and students. The results provide preliminary evidence that CARD™ is acceptable and appropriate for implementation in grade 9 school-based immunizations.

Managing immunization stress-related response: A contributor to sustaining trust in vaccines

Adverse events following immunizations (AEFI) are important to identify and manage effectively so as to sustain trust in vaccines and optimize health. The AEFI category related to "anxiety about the immunization" was considered problematic as it did not adequately capture the range of stress responses that can occur. The currently used term for this category, immunization stress-related responses (ISRR), is broader, including the full spectrum of signs and symptoms that can arise in response to stress. ISRR can include vasovagal reactions (fainting), hyperventilation and functional neurological symptoms (e.g. weakness, nonepileptic seizures). It is based on a biopsychosocial framework in which biological (e.g. age, sex), psychological (e.g. preparedness, previous experiences, anxiety) and social factors (e.g. response by others, social media) interact to create an individual's stress response to the immunization process. New guidance is available on prevention, early detection and management of ISRRs which is summarized in the article.

Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline

BACKGROUND

Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.

METHODS

Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.

RESULTS

The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.

CONCLUSION

In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.

Overview of a Knowledge Translation (KT) Project to improve the vaccination experience at school: The CARD™ System

Background

Students experience fear, pain, and fainting during vaccinations at school. While evidence-based interventions exist, no Knowledge Translation (KT) interventions have been developed to mitigate these symptoms. A multidisciplinary team—the Pain Pain Go Away Team—was assembled to address this knowledge-to-care gap. This manuscript provides an overview of the methodology, knowledge products, and impact of an evidence-based KT program developed and implemented to improve the vaccination experience at school.

Methods

We adapted knowledge and assessed the barriers to knowledge use via focus group interviews with key stakeholder groups involved in school-based vaccinations: students, nurses, school staff, and parents. Next, we developed project-specific goals and data collection tools and collected baseline data. We then created a multifaceted KT intervention called The CARD™ System (C-Comfort, A-Ask, R-Relax, D-Distract) to provide a framework for planning and delivering vaccinations using a student-centred approach. Selected KT tools from this framework were reviewed in additional focus groups held in all stakeholder groups. The multifaceted KT intervention was then finalized and implemented in stages in two projects including grade 7 students undergoing school vaccinations and impact on student outcomes (e.g., symptoms of fear, pain, dizziness) and process outcomes (e.g., utilization of interventions that reduce student symptoms, vaccination rate) were assessed.

Results

Participants reported that improving the vaccination experience is important. Based on participant feedback, an evidence-based multifaceted KT intervention called The CARD™ System was developed that addresses user needs and preferences. Selected KT tools of this intervention were demonstrated to be acceptable and to improve knowledge and attitudes about vaccination in the stakeholder groups. In two separate implementation projects, CARD™ helped grade 7 students prepare for vaccinations and positively impacted on their vaccination experiences. CARD™ improved vaccination experiences for other stakeholder groups as well. There was no evidence of an impact on school vaccination rates.

Conclusion

We developed and implemented a promising multifaceted KT intervention called The CARD™ System to address vaccination-associated pain, fear, and fainting. Future research is recommended to determine impact in students of different ages and in different geographical regions and clinical contexts.