The Journal of School Nursing2024, Vol. 40(3) 257–265© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221076137journals.sagepub.com/home/jsn
Background: While vaccines have reduced the incidence of vaccine-preventable diseases, vaccine hesitancy threatens the reemergence of childhood infectious diseases. Purpose: This randomized controlled study evaluated an online vaccine education program to advance vaccine acceptance among middle-school students. Methodology: Study participants were randomly assigned to an intervention group who viewed the VEP videos or to a comparison group who viewed a science-based video unrelated to vaccines. Results: Knowledge scores improved in both groups and more favorable shifts in vaccine-related beliefs and attitudes occurred in the intervention than in the comparison group. Conclusions: This program can be feasibly delivered via an online platform to middle school students, resulting in shifts in vaccine-related knowledge, beliefs and attitudes. Implications: Delivering evidence-based content to instruct about vaccine effectiveness and safety is an area in which school nurses have demonstrated an important role as a resource for patient education to promote vaccine advocacy.
Keywords
Communicable diseases, Health Education, Immunizations, Media (TV, computer, Internet), Middle/Junior/High School, School Nurses, Quantitative Research
Vaccines have been considered as one of the greatest scientific achievements and most effective global health interventions of the 20th century, responsible for significantly reducing morbidity and mortality from vaccine preventable diseases (VPDs) (Andre et al., 2008). Along with clean water, vaccines have been the single most effective public health practice that has reduced morbidity and mortality from most infectious diseases by 90 percent (Plotkin, 2004). Immunizations have saved 6.4 million lives, avoided 426 million illnesses, and prevented disability due to meningitis in 63,000 children (Ozawa & Stack, 2013).
Despite this impressive record, there is a growing movement of vaccine hesitancy among a faction of individuals in the United States and the world (Lane et al., 2018). The 1998 publication by Wakefield questioning the safety of the measles, mumps and rubella (MMR) vaccine intensified concerns about vaccine safety and despite being disputed by large-scale epidemiologic studies, the report has contributed to public mistrust in vaccine safety (Wise, 2018). Historically, some of the major issues that have contributed to vaccine hesitancy are: (1) lack of perceived risk of vaccine-preventable diseases, (2) perception that risks exceed benefits, and (3) influence of anti-vaccination media (Lane et al., 2018). There is also a pervasive perception that mandatory vaccine programs invade parents’ civil rights, including the right to refuse immunizations (Zimmerman et al., 2005). The convergence of these and other factors has fuelled the anti-vaccine movement (Parker, February 6, 2015).
Concerns about the growing number of measles cases in nearly three decades in the U.S., particularly among unvaccinated individuals (Patel et al., 2019), was eclipsed by the advent of SARS-CoV-2 related coronavirus disease 2019 (COVID-19) in December 2019. Since then, the SARS-CoV-2 virus has rapidly progressed into a worldwide pandemic, with nearly 200 million confirmed cases and more than 4 million deaths as of this writing (World Health Organization, 2021, July 27). Highly effective COVD-19 vaccines that can induce protective immunity against the virus are currently available; however, pervasive vaccine hesitancy by significant segments of the public is thwarting this goal (Puri et al., 2020).
Methods to increase vaccine acceptance have largely focused on three broad strategies: informational (i.e., educational vaccine programs designed to increase knowledge of vaccines and/or VPD); behavioral (i.e., strategies to influence vaccine decision-making, such as digital reminders sent to parents); and environmental (i.e., societal-level strategies, such as widespread public health campaigns) (Walling et al., 2016). Most educational programs designed to improve vaccine acceptance have targeted parents and have focused on influencing mediators (i.e., changing knowledge, beliefs and attitudes) to impact eventual outcomes of increasing vaccination rates (Kaufman et al., 2018).
Since the approval of the human papilloma virus (HPV) vaccine in 2006, there has been increased interest in vaccine education research in adolescents and young adults. Two systematic reviews demonstrated that vaccine educational programs, ranging from a single 10-minute session to one-hour presentations by healthcare professionals, significantly increased adolescents’ knowledge and vaccine-related attitudes at post-intervention (Fu et al., 2014). However, it is unclear whether such positive shifts translate into improved vaccine uptake.
As trusted healthcare professionals, school nurses are in a unique frontline position to identify patterns of vaccine hesitancy and provide reliable vaccine information to parents and adolescents (Luthy et al., 2016). School nurses recognize the importance of prioritizing communicable disease prevention for adolescents in particular, given that they represent a subpopulation who continue to have low immunization rates and have many school-related activities (e.g., sports physicals, camp, health fairs) that are ideal intersections to promote vaccine advocacy (Grace, 2006).
The current study focuses on a novel Vaccine Education Program (VEP), designed to provide evidence-based information about vaccines, dispel misperceptions, and enhance informed decision-making about vaccines. The goal of the present study was to pilot-test the video-based VEP via an online platform to middle-school children in the Maryland and Virginia public school systems. The study objectives were to: (1) determine whether shifts in vaccine-related knowledge and beliefs and attitudes (beliefs and attitudes) occurred from pre- to post-intervention in the intervention and comparison groups and (2) collect information about participants’ satisfaction with the VEP program content and delivery.
The VEP curriculum was developed by the principal investigator (E.L.) with input from leading vaccine experts and educational specialists. The program consists of thirteen videos, covering topics about vaccine development, herd immunity, and topic-specific information about vaccines administered to adolescents (i.e., pertussis, meningococcus, influenza, and human papilloma virus (HPV)). As the current study was initiated prior to the COVID-19 pandemic, no COVID-specific vaccine module was included in the educational program; however, one such module is currently in development. Although the program was developed in 2013, the content was thoroughly reviewed by subject matter experts for recency and accuracy prior to commencement of this study. The VEP videos and their length are shown in Supplemental Digital Content 1; the entire program is publicly available and accessible at https://tinyurl.com/VaccineEducationProject.
The study was approved by Georgetown University’s Institutional Review Board (IRB). The initial implementation plan was to deliver the VEP curriculum in-person with the support of Maryland’s Montgomery County Public Schools (MCPS) 7th grade science teachers during or immediately after school hours. This plan was revised due to scheduling and logistical challenges and the entire study was conducted virtually on a secure network using the Enterprise (Institutional) version of SurveyMonkey. This allowed study participants to access the site and complete the study requirements at a convenient time.
Recruitment. Study participants were drawn from 7th grade students enrolled in the MCPS and Virginia public school systems. The primary method of recruitment was to distribute IRB-approved recruitment flyers to all 40 MCPS middle schools using a phased and stratified sampling method based on schools’ average standard scores, such that each of the four recruitment phases had representation from all quartiles to maximize equitable distribution. Recruitment flyers were placed in centrally located school areas where 7th grade students could bring them home to share with their parents and interested parents then contacted the study Research Coordinator (RC) by phone or by email.1
Screening and Enrollment. Screening was conducted by the RC with a parent via phone or email to ensure that the student met eligibility criteria; that is, a current 7th grade student in the MCPS or Virginia public school system with access to a computer or mobile device with internet access for the 60–90-minute study duration. An email was sent to the parent containing a hyperlink to the online informed consent and assent documents for review and signature by the parent and child. After both the parent and child signed the documents, the students were officially enrolled in the pilot.
A list of three-digit study identification (ID) numbers was created a priori and each slot was randomly assigned to one of two groups (vaccine/intervention or control/comparison) using a random number generator (accessed at www.random.org). This file was stored in a separate double-password protected Excel file. When new study participants enrolled, they were sequentially assigned to the next available study ID and then received an email from the RC with their randomization assignment, unique study ID number, and a hyperlink to either the online vaccine or control videos.
The main outcomes of interest included acquisition of vaccine-related knowledge, shifts in vaccine-related beliefs and attitudes, and satisfaction with the VEP video content and delivery. Since a review of the literature failed to identify a set of validated outcome measures suitable for this study, several customized surveys were created by the research team to measure knowledge, beliefs, attitudes and satisfaction (Supplemental Digital Content 2).
Knowledge Questions. The 10 knowledge questions with multiple-choice response options reflected core concepts about vaccines and immunity contained in the VEP vaccine videos (Supplemental Digital Content 2). The knowledge questions were reviewed and edited by the co-authors and subject matter experts on the VEP Advisory Board. The questions were also reviewed by teachers to assure that wording and content were at an age-appropriate level.
Beliefs and Attitude Questions. A second outcome of interest was to determine whether there were changes in vaccine-related beliefs and attitudes after participants watched the videos. A search of PubMed and the Health and Psychosocial Instruments (HaPI) databases did not locate any surveys that directly measured adolescents’ beliefs about vaccines. However, a study of parents’ beliefs and attitudes about vaccines found strong associations between specific beliefs and intention to vaccinate their children (Prislin, Dyer, Blakely, & Johnson, 1998). Based on this study’s findings, six vaccine-related beliefs most relevant for adolescents with the highest factor loadings (range 0.53 to 0.86) were chosen (Supplemental Digital Content 3). Specifically, these were beliefs about the effectiveness of vaccines (I wonder if the vaccine they give to my child works), natural immunity (It is better for a child to develop immunity by getting sick than to get a vaccine), the protective value of vaccines (Immunizations are the best way of protecting my child against dangerous childhood diseases), and safety concerns (Immunizations can do more harm than good). For the current study, the wording of these statements was changed to first person voice from the adolescent’s perspective. Participants were asked to respond to each statement on a five-point Likert scale (i.e., strongly agree, agree, neutral-neither agree nor disagree, disagree, strongly disagree) prior to and after watching the videos (Supplemental Digital Content 3).
Satisfaction Questions. Five satisfaction questions asked participants in the intervention group to express their agreement/disagreement with statements about whether their perspectives about vaccines had changed, whether they planned to share the information with parents, and whether they thought that the videos presented a balanced picture of the pros and cons of vaccines (Supplemental Digital Content 2). An open-ended textbox encouraged participants to share their opinions about what they liked and did not like about the program content, what they remembered, what they would most likely be willing to share with others, and any suggestions for improvement. Intervention Delivery
Participants were asked to set aside 90 minutes at a convenient time and place to participate in the study. During the intervention phase of the study, participants completed the pre-test survey (10 knowledge, 6 beliefs and attitudes questions), viewed the assigned videos, and then completed the post-test survey (10 knowledge, 6 beliefs and attitudes), and for the intervention group only, the satisfaction questions. Participants accessed a hyperlink that directed them to either view the VEP videos (intervention group) or to a National Geographic video called “Chemistry of Cells” (control group) which contained detailed information about the biology, structure, and life cycle of cells with no reference to vaccines or the immune system. Both sets of videos were equivalent in complexity of scientific information and in program length (59 minutes).
The online questionnaires contained no personally identifying information and all data entered by participants were linked to their unique three-digit study ID. A Microsoft Excel master list was the single source that linked study participants’ contact information with their unique study ID. At the completion of the study, all data from the online questionnaires were downloaded by the RC into an Excel file. These electronic documents were maintained in a doublepassword protected shared folder, accessible only to the research team.
Due to the exploratory nature of the study, sample size calculations were not performed. An a priori algorithm was developed to score test results and conduct qualitative data analyses (as described in Supplemental Digital Content 3). Quantitative average pre-test knowledge scores were compared between the vaccine and control groups using the Wilcoxon rank-sum test. Within each group, the McNemar test was used to compare changes in knowledge question scores between pre- and post-intervention. A generalized linear mixed effects model was used to determine the occurrence of any differential changes in knowledge scores between the two groups. Analysis of covariance (ANCOVA) was conducted to determine the impact of the intervention on pre- to post-intervention changes in average knowledge scores between vaccine and control groups. Aggregated proportions of vaccine-related beliefs and attitudes (i.e., positive, neutral, negative) between the two groups at pre-intervention were compared using a Chi-squared test. Within each group, changes in beliefs and attitudes between pre- and post-intervention were tested using the McNemar test, followed by ANCOVA to test the group difference while adjusting for the baseline beliefs and attitude scores. Five categories of pre- to post-test shifts in beliefs and attitudes (i.e., favorable, no shiftpositive; no shift-neutral; no shift-negative; unfavorable) were compared using the Fisher’s exact test. Statistical significance was determined if a two-sided P<0.05. All tests were conducted using the statistical software package, R version 3.4. The satisfaction data were scored using descriptive analyses of the proportion of responses in each of the five categorical options.
Fifty students from 13 schools were screened for eligibility; of these, 47 were enrolled in the study and randomly allocated to the intervention group (n=19) or comparison group (n=28). There were 17 study completers in the intervention group and 22 in the comparison group. A study completer was defined as a participant who was enrolled in the study, viewed the online videos, and completed both preand post-test surveys. The intervention group completers were 65% male with a mean age of 12.47 years. The comparison group completers were 50% male with a mean age of 12.41 years. Shown in Figure 1 is a CONSORT diagram showing a summary of recruitment, screening, enrollment, and study completion rates.
Shown in Table 1 are the pre- and post-test knowledge scores (% correct for each of the 10 questions) at pre- and postintervention for each group. Baseline knowledge scores were higher in the vaccine group than in the comparison group, but the differences were not statistically significant (73% vs. 64%, p=0.11). Although both groups had higher post-test knowledge scores compared to pre-test values, the vaccine group had greater improvement than the comparison group (mean difference, 13% vs. 10%, respectively); however, there were no statistically significant differences between group differences overall (p=0.77) or at the individual question level.
Each individual question-level response was coded as either “positive”, “neutral”, or “negative” based on which response option a participant chose (i.e., agreed/strongly agreed, neither agreed nor disagreed, disagreed/strongly disagreed with positively or negatively worded vaccine-related beliefs). Positive responses were those that were consistent with vaccine acceptance, negative with vaccine hesitancy, and neutral as no opinion.
Baseline Beliefs and Attitudes. At baseline, attitudes were overwhelmingly positive in both the intervention and comparison groups (overall average, 76%) with a higher proportion of positive vaccine-related beliefs in the comparison compared to the vaccine group (80.3% vs. 72.5%). Although less than 10% of responses in each group were negative at baseline, there was a higher proportion of negative responses in the vaccine group when compared to the comparison group (9.8 vs. 6.1%). Baseline differences between groups in each response category were not statistically significant (p=0.35).
Pre- to Post-test Shifts in Beliefs and Attitudes. Pre- to post-test shifts in beliefs and attitudes between the vaccine and comparison groups are shown in Table 2. For each response from pre to post-test, there were five possible outputs: favorable shift, no shift (stayed positive), no shift (stayed neutral), no shift (stayed negative), or unfavorable shift. There were no changes in two-thirds (66.7%) of the vaccine group and in approximately three-quarters (78.0%) of responses in the comparison group (p=0.055), more than half of which were positive vaccine beliefs and attitudes that remained positive. There was more than a two-fold shift toward positive vaccine beliefs and attitudes in the vaccine compared to the comparison group (27.5% vs. 12.1%, p<0.01) and a greater proportion toward more negative vaccine-related beliefs and attitudes in the control group than in the vaccine group, but the difference was not statistically significant (9.8% vs. 5.9%, p=0.34) (Figure 2).
There was high overall satisfaction with VEP videos; all vaccine-group participants either ‘strongly agreed’ (76%) or ‘agreed’ (24%) that the VEP videos helped them understand the importance of vaccines and 96% either ‘agreed’ or ‘strongly agreed’ that the videos presented a balanced picture of vaccine pros and cons (Figure 3). The majority strongly ‘agreed’ (65%) or ‘agreed’ (29%) that they planned to share what they learned from the videos with their parents. Seventy seven percent of participants ‘strongly agreed/agreed’ that watching the videos changed their perspectives about receiving vaccines. Of note, the 12% who strongly disagreed with this statement endorsed positive vaccine-related beliefs and attitudes, suggesting that their perspectives did not change since they were already supportive of vaccines at baseline.
Open-ended Comments. Nine vaccine group participants provided responses to open-ended questions about the VEP videos. Responses included statements that the VEP videos were “very educational”, “very interesting and cool”, “really good” “thoroughly explained everything” and were “easy to understand for 7th graders”. One respondent stated “it seems like a lot of people don’t get vaccinated because they don’t think vaccines really work and that they might cause more harm than good. So, the videos really explain how important vaccinations and immunity to these viruses really is.” Another commented on the “true stories” in the videos, stating that they were “really emotional and convinced me to get a flu shot.” One stated “I will never fight about getting a vaccine again I now know that they can save lives”. There were no statements that expressed negative views of the VEP videos.
The present study evaluated whether a video-based vaccine education program delivered via an online platform to 7th grade students resulted in changes in vaccine-related knowledge, beliefs and attitudes. The program was successfully delivered and results showed favorable shifts in vaccine-related beliefs and high satisfaction with program content.
Although the study found that knowledge scores in the vaccine group improved more after watching videos than the control group, there were no statistically significant differences between the two groups. The paradoxical improvement in knowledge scores in control participants is difficult to explain, since the control video contained no pertinent information about vaccines or the immune system. It is possible that these students may have searched online for answers to the survey questions or received assistance in answering the questions. Another possible explanation is that the survey itself had issues with construct validity. For several questions, participants’ scores at baseline were already very high, providing little opportunity for improvement. While these questions were developed by subject matter experts and thoroughly reviewed and edited by others, their validity and reliability were not measured prior to implementation in this study. Ideally, in subsequent research studies, such knowledge content should undergo rigorous testing to ensure that they accurately and reliably measure concepts related to vaccines and the immune system and are age-appropriate for young adolescents.
Another study finding of interest was that vaccine-related beliefs and attitudes were overwhelmingly positive in both groups at baseline with 76% of all study participants showing positive attitudes about vaccines at the beginning of the study. This could be related to inherent selection biases in that parents who are supportive of vaccines would be more likely to allow participation of their children in the study, whereas those with negative views about vaccines would not be as willing. Not surprisingly, when postinterventive shifts in beliefs and attitudes were analyzed, the majority of responses showed no change in these positive beliefs about vaccines in either the vaccine group (67%) or comparison group (78%). However, there was more than a two-fold shift towards positive beliefs among participants who viewed the VEP videos as compared to those viewing the control video. More participants with neutral or negative beliefs at the beginning of the study shifted to more positive attitudes in the vaccine, as compared to the control group after viewing the videos.
Another significant study finding was the positive satisfaction ratings about the VEP videos among study subjects who viewed the vaccine video. Participants agreed that the videos helped them understand the importance of vaccines and presented a balanced picture of vaccine-related pros and cons. All of the open-ended participant comments reflected a positive opinion of the videos. While it is likely that participants who enter a study such as this would reflect the positive attitudes towards vaccines of their parents, the high satisfaction ratings support the perceived acceptability of the VEP video series among this cohort of young adolescents.
This study addressed a major barrier to adolescent vaccination; a lack of knowledge of vaccines and VPDs (Blanchard et al., 2020). Results indicated the majority of adolescents already had basic knowledge about vaccines and positive vaccine-related beliefs and attitudes at baseline. The finding that intervention group participants had greater favorable shifts in beliefs and attitudes than the control group offers promise that vaccine education programs can lead to positive changes in adolescent perceptions and beliefs about vaccine safety and risks of VPDs.
There are several limitations of the present study. The onset of the COVID-19 pandemic that occurred three months into the study severely limited our recruitment efforts and resulted in the enrollment of only 47 participants, of which 39 were study completers. However, the choice to implement the study via an online platform permitted the continued recruitment and enrollment of participants throughout the period of physical distancing that would have been severely compromised with in-person study delivery. One of the shortcomings of delivering the study via an online platform was that it was not possible to monitor whether participants completed the knowledge pre/post surveys without directly searching for answers online. Additionally, although favorable shifts in beliefs and attitudes occurred, these are not necessarily indicators or predictors of behavior change.
This program has particular relevance for school nurses, as healthcare educators who can provide evidencebased information about the safety and effectiveness of vaccines and dispel misconceptions to address vaccine hesitancy (National Association of School Nurses, 2020). One potential application of the VEP videos is to conduct further implementation studies by school nurses, particularly for school staff, students and their parents who have misgivings about vaccines. Since the videos are publicly available and accessible on the internet, they can be viewed at times when it would be most convenient for busy families, obviating the potential challenges of delivering this education in the school setting (Luthy et al., 2011).
One of the most formidable challenges in the age of COVID is pervasive vaccine hesitancy (Bellanti, 2021). A recent survey found that in addition to concerns about safety and effectiveness of currently available vaccines, reliance on social media for information and belief in conspiracy theories contribute significantly to respondents’ reluctance to receive a COVID-19 vaccine (Ruiz & Bell, 2021). Clearly, there is a critical need to develop targeted public health campaigns to address knowledge deficits, beliefs, attitudes, and health perceptions that give rise to COVID-19 vaccine hesitancy. While such beliefs and attitudes are difficult to overcome, nurses in other settings have successfully implemented innovative methods to identify and counsel patients with vaccine hesitancy (Connors et al., 2018; Dugani et al., 2021; Koslap-Petraco, 2019; Wermers et al., 2021).
The present study demonstrates that a vaccine education program delivered via an online platform is an acceptable and feasibly delivered method to disseminate evidence-based information and results in favorable attitude shifts among young adolescents. Further research to test the program’s effectiveness with a broader range of outcome measures in other populations would be useful to make conclusions about its further utility and generalizability.
EBL designed and produced the VEP videos; conceptualized and oversaw the study; reviewed and provided final approval of manuscript. DMB contributed to study design; conducted analyses; wrote methods, results, and discussion sections. CCB conducted screening, enrollment, and data collection; wrote sections and edited manuscript. WAO provided scientific oversight; reviewed, edited, and provided final approval of manuscript. JAB conceptualized and oversaw the study; conducted recruitment; wrote introduction and discussion sections; reviewed, edited, and provided final approval of submitted manuscript.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Supported in part by a research grant from the Investigator- Initiated Studies Program of Merck Sharp & Dohme Corp and in part by a grant from the Martyn A. Vickers Sr, MD Endowment Fund, Georgetown University Medical Center. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp.
Joseph A. Bellanti https://orcid.org/0000-0002-5038-7202
Supplemental Digital Content 1: Vaccine Education Project Videos (pictures with hyperlinks to online videos)
Supplemental Digital Content 2: Knowledge, Beliefs and Attitudes, and Satisfaction Questions (tables)
Supplemental Digital Content 3: Beliefs and Attitudes Survey Development and Scoring Rubric (text, tables)
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1 Department of Pediatrics, Georgetown University Medical Center, Washington, DC,
2 Clinical Research Consultant, Project Manager, ICF International Inc.
3 Research Consultant and Coordinator, ICF International Inc.
4 Department of Pediatrics and Emory Vaccine Center, School of Medicine, Emory University, Atlanta, GA,
5 Department of Pediatrics and Microbiology-Immunology and
6 International Center for Interdisciplinary Studies of Immunology, Georgetown University Medical Center, Washington, DC
Corresponding Author:* Joseph A. Bellanti, M.D., Georgetown University Medical Center, 3900 Reservoir Road, NW, Room 308 NW, Washington, D.C. 20057, 202-687- 8227,Email: bellantj@georgetown.edu