Digital Repository Doctoral Projects Fall 2021 Improving Vaccination Rates of School-Aged Children in a Rural Community Rachel Hogge Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hogge, R. (2021) Improving Vaccination Rates of School-Aged Children in a Rural Community. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving Vaccination Rates of School-Aged Children in a Rural Community by Rachel Hogge A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director . Running head: LOW VACCINATION RATES 1 Improving Vaccination Rates of School-Aged Children in a Rural Community Rachel Hogge Annie Taylor Dee School of Nursing, Weber State University December 12, 2021 LOW VACCINATION RATES 2 Acknowledgments I would like to express my gratitude to the many people that provided support and encouragement to me with this DNP project. I would like to thank Dr. Mary Anne Reynolds, a professor at the Annie Taylor Dee School of Nursing at Weber State University, who served as my faculty project lead. She provided wisdom, encouragement, and one-on-one mentorship throughout the entire project. She was readily available and very eager to assist in any way that she could, especially as obstacles were encountered with the challenges that the COVID-19 pandemic presented. I would also like to express my appreciation to my DNP consultant, Cheryl Andreasen, the Weber-Morgan Health Department Immunization Department Manager. She was a strong project supporter, even throughout the challenges that the Health Department faced with COVID-19 testing and vaccine rollout. She provided immense expertise and assistance that is greatly appreciated. Lastly, I would like to thank my husband and four children. They have provided unending support, love, and encouragement, and have sacrificed much to help me complete this project and doctoral program. LOW VACCINATION RATES 3 Abstract Vaccines prevent deadly diseases. Despite success, vaccination rates are critically low for school-aged children in rural Morgan County, Utah. While vaccine hesitancy is often caused by perceptions regarding relative safety and effectiveness, it can also be driven by perceptions of convenience and complacency. The purpose of this Doctor of Nursing Practice project was to address vaccine hesitancy in a multifaceted, tailored approach to increase vaccination rates. This was accomplished by improving the Morgan Health Department’s vaccine clinic accessibility, creating an incentive program, distributing vaccine education, and promoting vaccines in the community. Parents at the clinic and from a community Facebook page were surveyed to assess the project's impact. Additionally, the number of vaccines administered at the clinic was recorded. Vaccine administration at the clinic increased from 1 in 2020 to 17 in 2021. All surveyed parents (N=6) at the clinic chose the convenient location in Morgan as a top reason for utilizing the clinic. Reminders and clinic hours were the second-highest choices selected. Sixty-nine percent of participants (N=40) on Facebook identified a school email and social media as important, while 28% selected community fliers as the most helpful methods for receiving vaccine information. Vaccines provide vital protection against serious illnesses; however, vaccine hesitancy often prevents many from receiving vaccinations. This project addressed vaccine confidence, as well as perceptions of convenience and feelings of complacency to improve vaccination rates so individuals and communities can benefit from the protection that vaccinations provide. Keywords: vaccines, vaccine hesitancy, rural vaccination, childhood vaccines, vaccine complacency, vaccine confidence, vaccine convenience LOW VACCINATION RATES 4 Improving Vaccination Rates of School-Aged Children in a Rural Community Vaccines have been named one of the most significant health advancements of the 20th century (Centers for Disease Control and Prevention [CDC], 1999). The CDC predicts vaccines will prevent 381 million illnesses, avoid 855,000 deaths, and save over a trillion U.S. dollars from those who were born between 1999-2016 and fully vaccinated (Messonnier, 2019). Vaccines have played a pivotal role in reducing or eradicating life-threatening and debilitating illnesses such as smallpox, polio, measles, rubella, and many other serious infectious diseases (Maglione et al., 2014). Due to various barriers to vaccination, over thirty percent of children in the United States are not receiving some of the critical vaccines as recommended, putting children at risk for contracting severe illnesses or death and placing communities at risk for outbreaks (CDC, 2019). Low vaccination rates are frequently related to vaccine hesitancy (Hill et al., 2019). Vaccine hesitancy is commonly associated with parental concerns about the safety and effectiveness of vaccines but is also driven by other factors, including an inconvenience of access, complacency towards vaccination, and lack of confidence in vaccine services (World Health Organization [WHO], 2014). Currently, vaccination rates of middle-school-aged children in Morgan County, Utah, are critically low at 69.6%, which is significantly lower than the state average of 90% (Utah Department of Health [UDOH], 2019). Being a rural community, inconvenient access is a significant barrier to vaccination for Morgan County children. Other factors of complacency and confidence also substantially contribute to their low vaccination rates. Vaccine hesitancy is a complex phenomenon that requires a tailored, multifaceted solution to improve vaccination rates (WHO, 2014). This Doctor of Nursing Practice (DNP) project aimed to improve vaccination rates by addressing factors of vaccine hesitancy of convenience, LOW VACCINATION RATES 5 complacency, and confidence through increasing accessibility of the Morgan satellite clinic, producing a community media and incentive program, and distributing vaccine educational material. Search Strategies To review the literature, a search was conducted in Google Scholar and databases contained in the Stewart Library OneSearch, such as CINAHL, EBSCO, PsychINFO, Medline, PubMed, and others. The following keywords were used for searches: vaccines, vaccine hesitancy, vaccine barriers, rural vaccination, childhood vaccines, school vaccines, vaccine complacency, vaccine confidence, vaccine convenience, vaccine programs, vaccine incentives, vaccine education, and vaccine accessibility. Literature Review At the beginning of the 20th century, infectious diseases infected people in large numbers of all ages, genders, and socioeconomic classes (CDC, 2018b). With the advancement of vaccines, both in safety and efficacy, vaccines have nearly eliminated, or in some cases, wholly eradicated frightening conditions such as polio, smallpox, and measles (CDC, 2018b). Despite the great success of vaccines, barriers to vaccination continue to prevent adequate coverage for many vaccine-preventable diseases (Esposito, Principi, & Cornaglia, 2014). A review of the literature supports the safety and effectiveness of vaccines, identifies possible barriers to vaccination, and provides interventions that can be implemented to increase vaccine uptake. Vaccination Vaccines are medications that prevent individuals from contracting serious illnesses through the development of immunity (CDC, 2018a). The mechanism of action in acquiring immunity is similar to when the body is exposed to a pathogen without the resulting illness. LOW VACCINATION RATES 6 Vaccines produce immunity by various means of presenting antigens of pathogens to the body that elicit a response and cause white blood cells to produce memory cells for future invasions (CDC, 2018a). Vaccines provide effective protection for individuals who receive vaccines and protect individuals through herd immunity who cannot receive vaccines due to medical contraindications or unknowingly have waning immunity (CDC, 2018a). Supported by many organizations, such as the American Academy of Pediatrics and American Academy of Family Physicians (AAFP), the Advisory Committee on Immunization Practices (ACIP) provides guidelines for vaccinations, including vaccination type, schedules, dosages, and the number of doses (CDC, 2020). State laws and regulations are established from these recommendations, including school vaccine registration requirements (CDC, 2016). Primary care providers generally provide vaccines, but non-traditional sites, such as pharmacies, schools, and health departments, are safe and effective ways to deliver vaccines (Schaffer et al., 2014). School vaccine requirements vary by state and, depending on state legislation, grant exemption from vaccine requirements for medical, religious, or personal reasons (CDC, 2016). Utah state law permits all three types of exemptions (Utah State Legislature, 2019). By following these recommendations, vaccines have provided immense progress in preventing life-threatening infectious diseases and have significantly saved health care dollars (Messonnier, 2019). Before vaccinations, serious diseases like polio, smallpox, and measles were common illnesses that took thousands of lives every year in the United States (CDC, 2018b). Although these diseases are becoming less prevalent in the United States due to adherence to vaccination guidelines and recommendations, these diseases have not disappeared globally (CDC, 2018b). Infected individuals can import vaccine-preventable diseases from these regions of the world. In 2011, when measle cases were nearly non-existent in the United States, there were more than LOW VACCINATION RATES 7 350,000 cases worldwide (CDC, 2018b). Without continued high vaccination rates, the diseases that vaccines have nearly eradicated in the United States could return to pre-vaccination numbers. Pockets of low vaccination rates are particularly at risk for outbreaks as they disrupt herd immunity (Salmon, Dudley, Glanz, & Omer, 2015). Despite continued reports of the safety and efficacy of vaccines, for more than a decade, the rate of nonmedical vaccination exemptions has been increasing (Salmon et al., 2015). Salmon et al. (2015) believe that vaccine hesitancy is a significant contributor to these statistics. Increased vaccine exemptions have been associated with epidemics. In a systematic review investigating several vaccine-preventable disease outbreaks, Phadke, Bednarczyk, Salmon, and Omer (2016) found that up to 93% of affected unvaccinated individuals were intentionally unvaccinated. Additionally, rates of vaccine refusal were associated with an increased risk of infection for fully vaccinated individuals, related to waning immunity. Vaccination rates still need improvement, with approximately only 68.3 % of 24-month-old children in the United States fully vaccinated (CDC, 2019). Despite continued vaccine efficacy, demonstrated safety, and availability, or perhaps even because of vaccine success, increasing numbers are reluctant or refuse vaccination (American Academy of Pediatrics, n.d.). Vaccine Hesitancy The rate of unvaccinated children less than two has quadrupled since 2001 and is believed to be related to vaccine hesitancy (Williams, 2019). In 2019, WHO (n.d.) identified vaccine hesitancy as one of the top ten threats to global health. WHO (2014) describes vaccine hesitancy as a refusal or even just a reluctance to vaccinate. Further, Siddiqui et al. (2013) describe vaccine-hesitant individuals or caregivers as those who experience any degree of uncertainty towards complete or timely vaccination of themselves or their children. LOW VACCINATION RATES 8 Considering growing concerns about the effects of vaccine hesitancy, the Sage Working Group was commissioned by WHO to identify the determinants of vaccine hesitancy (WHO, 2014). Three significant factors of vaccine hesitancy were identified: 1) inconvenience in access, 2) complacency towards vaccination, and 3) lack of confidence in vaccines or vaccine services. These factors were identified as the 3C’s of vaccine hesitancy of convenience, complacency, and confidence. Understanding each of the underlying factors of vaccine hesitancy is critical to developing successful strategies in improving vaccination rates. Although there is widespread availability of vaccines, logistical and geographical challenges may prevent convenient access to vaccines and contribute to vaccine hesitancy (Messonnier, 2019; WHO, 2014). These barriers may include high vaccine costs, inconvenient operational times of clinics, location inaccessibility, lack of vaccine reminders, long distances to vaccine services, and vaccine provision that individuals may not consider comfortable or appealing (WHO, 2014). Stubbs et al. (2014) discovered that students who lived closer to vaccine clinics were more likely to utilize the services. The CDC supports this finding and reports that in rural communities, which are more likely to face geographical barriers, vaccination rates are three to seven percent lower (Messonnier, 2019). The cost of vaccines is also a significant barrier to vaccination that affects convenient access. Typically, in the United States, private and public insurances provide complete coverage for vaccines, but vaccine costs are substantial if uninsured or underinsured. Although government programs exist, such as the Vaccines for Children (VFC) program, which provides vaccines free of charge for the uninsured, if individuals do not have convenient access to the program, the high costs of vaccines may inhibit vaccine uptake (UDOH, n.d.b). Gallagher et al. LOW VACCINATION RATES 9 (2016) identified that one of the most significant factors that affect the completion of multi-dose vaccine schedules by adolescents is inadequate health insurance coverage. Complacency is another significant barrier to vaccination. During times when outbreaks are not a current threat, families and even providers may become complacent to the risks of vaccine-preventable illnesses. Furthermore, since most families have never seen cases of these diseases covered by routine vaccines, the need to vaccinate may feel less urgent or not needed, leading to a lack of motivation to vaccinate (Messonnier, 2019). These thoughts can stem from a belief in a lack of risk from vaccine-preventable diseases or influenced by media from anti-vaccinators (WHO, 2014). Complacency has been called a disease of those that live in countries with stable governments, sturdy health systems, and good sanitation. Unfortunately, the cure for complacency is often an outbreak (Kane, 2001). Confidence in vaccines relates to trust in the safety and effectiveness of vaccines and the reliability of the services providing them (WHO, 2014). Individuals that lack confidence in vaccines come from all socioeconomic classes, ages, and genders (Siddiqui et al., 2013). Confidence can be positively affected by recommendations from trusted sources, such as health care workers (Freed, Clark, Butchart, Singer, & Davis, 2011). Further education on the safety and effectiveness of vaccines can affect the degree of confidence that parents feel towards vaccine acceptance (Frew & Lutz, 2017). Unfortunately, confidence can also be significantly negatively impacted by anti-vaccination media messages (WHO, 2014). Salmon, Moulton, and Omer (2005) found that parents of vaccine exempt children were significantly more likely to report feelings of low safety and efficacy of vaccines; low trust in medical, public health care, and government sources; and a self-perceived low susceptibility to and low severity of vaccine-LOW VACCINATION RATES 10 preventable illnesses. These findings suggest that vaccine-hesitant parents need further education and efforts by providers and public entities to establish relationships of trust. Although vaccine uptake is affected by vaccine hesitancy, high vaccination rates may not reveal the level of uncertainty that individuals or parents are experiencing. Raithatha, Holland, Gerrard, and Harvey (2003) found that parents who vaccinate their children continue to have significant concerns about vaccination. It is important to consider that parents that vaccinate may reconsider vaccinating if vaccine barriers are not addressed. Those that are vaccine-hesitant have been described to be on a spectrum from full-acceptance despite hesitancy, acceptance of some vaccines or altered time-schedules, to complete refusal of all vaccines (Siddiqui et al., 2013). Addressing Vaccine Hesitancy Vaccine hesitancy is a complex phenomenon that requires a multifaceted, tailored approach to improve vaccination acceptance (WHO, 2014). It is important to address accessibility as it relates to convenience. Education and promotion are essential when looking at confidence and complacency. Further, complacency can be addressed by providing motivation to parents to vaccinate. The convenience of access can be affected by various aspects such as vaccine costs, clinic hours, location of services, geographical barriers, and other factors. An effective intervention includes providing more convenient clinic hours by catering to school and work schedules (Stinchfield, 2008). The barrier of vaccine costs can be mitigated by convenient access to programs that offer free vaccines (Esposito et al., 2014). Text message reminders are also an effective way to increase convenience and uptake of vaccines (Esposito et al., 2014). Providing locations that are easily accessible and that are deemed safe and comfortable is an intervention that can be implemented (WHO, 2014). Barriers of geographical distances can be LOW VACCINATION RATES 11 alleviated in rural areas by providing vaccines at alternate locations such as schools, pharmacies, and health departments (Schaffer et al., 2014). Traditionally the medical home is the venue for vaccination, especially for infants and toddlers. As children age, adolescents visit their health care providers less frequently, making vaccination challenging to complete on time, or if at all (Daley et al., 2014). Other non-traditional sites of vaccinations, such as the local health department immunization clinics, are typically considered a safety net for those that do not have an established medical home or cannot afford vaccination. Shaffer et al. (2014) found that 98% of health departments provide adolescent vaccinations and that the services of health department clinics are considered a safe and an available option for vaccination. Vaccination increases by utilizing community venues for adolescents or those less likely to receive medical care from conventional sources. The use of health department immunization clinics offers a feasible solution to the barrier of inconvenient access and should be considered a viable option for improving low vaccination rates. Vaccine confidence is rooted in understanding the safety and effectiveness of vaccines and vaccine services (WHO, 2014). Providing vaccine education can close the gap of understanding (Frew & Lutz, 2017). Although offering extensive parental education may seem necessary, WHO (2014) suggests simply providing one or two vaccine messages in vaccine media campaigns. These messages can initiate thoughts about vaccines and encourage vaccine acceptance. Also, using positive messages in media campaigns, opposed to risk awareness, is an effective approach to safeguarding against anti-vaccine messages (Wong, 2016). Vaccine education can empower individuals and caregivers to make informed decisions and feel confident about their choices. LOW VACCINATION RATES 12 There is a vast array of sources of information available for individuals and parents to consult when making decisions regarding vaccination. Parents have identified the health care provider as the most trusted source of vaccine information (Freed et al., 2011). Additionally, the AAP (n.d.) has stated that as high as 98% of parents surveyed agreed that they follow the advice of their health care provider. This high regard and compliance with health care provider recommendations provide a critical role for the provider in increasing the confidence of individuals and parents of those to be vaccinated. Additionally, the AAP (n.d.) recommends providers use a presumptive versus participatory approach when recommending vaccinations to parents. This approach has been associated with greater vaccine acceptance (AAP, n.d.). Using a strong provider recommendation is a method that could be taught to providers through a formal educational program as a possible solution to increase vaccination rates that counter lack of confidence in vaccines or even complacency of those that are vaccine-hesitant. Complacency is also a significant barrier to consider in vaccination efforts. Individuals and caregivers experience complacency when vaccination is deemed unnecessary or is placed at a lower priority than other life responsibilities, resulting in a lack of motivation to vaccinate (WHO, 2014). Incentive programs are an evidence-based recommendation for increasing vaccinations by increasing motivation (Community Preventive Services Task Force [CPSTF], 2015). Small, monetary, or non-monetary incentives for individuals and families are effective, including gift cards, food vouchers, baby items, lottery prizes, etc. (CPSTF, 2015). Evidence suggests that incentive programs are effective in clinical and community settings and recommended to be widely implemented (CPSTF, 2015). LOW VACCINATION RATES 13 Summary Vaccines provide vital protection against preventable illnesses and death. Vaccine safety and effectiveness have been demonstrated over time, yet many are reluctant or refuse to vaccinate. Vaccine hesitancy has been rising and can lead to dangerous outbreaks that render people at risk for developing life-threatening diseases. Driving factors that should be considered when approaching vaccine hesitancy include inconvenience in access, complacency towards vaccine-preventable illnesses, and lack of confidence in vaccines and vaccine services. When these factors are addressed in a multifaceted, tailored practice change, such as increasing accessibility of the Morgan satellite clinic, providing a community vaccine promotion and incentive program, and distributing vaccine and vaccine resources educational material, vaccination rates in Morgan County can be improved. Project Plan and Implementation Lewin’s Force Field Theory of Change Lewin’s Force Field Theory is a dynamic model that identifies three successive stages involved in the process of change (Finkelman, 2018). The three steps of the model are unfreezing, change, and refreezing. After a need for a change is recognized, the first stage of unfreezing includes identifying the forces that oppose or encourage the needed change. During the change stage or also called the moving stage, interventions are implemented to obtain the desired outcomes. Implementation of driving or restraining forces disrupt the existing equilibrium and allows for a different result or desired outcome. The final stage of the theory is the refreezing stage. During this step, the goal is to create new habits that will sustain the change in the future. Without this final stage, the old behaviors may return. LOW VACCINATION RATES 14 Lewin’s Force Field Theory is a theory that guided the DNP project in addressing the problem of low vaccination rates. Vaccine uptake is the result of a delicate balance of facilitating and opposing factors. Applying the first phase of Lewin’s Theory to the DNP project, the driving and opposing factors were identified (Finkelman, 2018). For vaccination, WHO (2020) has identified vaccine hesitancy as a primary barrier to vaccine acceptance, influenced by convenience, complacency, and confidence. During the change phase, the identified factors were altered to increase vaccine acceptance. The final stage of the theory is the refreezing of the change. In a practice change project, this step was equally as vital as the first two steps. The change will be sustained through stakeholder buy-in and newly established procedures of the satellite vaccine clinic that address the three components of vaccine hesitancy. Project Goal and Objectives The primary goal of this DNP project was to improve vaccination rates of school-aged children in Morgan County, Utah. To successfully achieve this goal, three objectives were identified. The first objective was to improve the accessibility of the Morgan County satellite vaccine clinic for school-aged children of Morgan County. The second objective was to produce a marketing and incentive program targeted at Morgan County school-aged children and parents. The final objective was to develop and distribute vaccine educational material regarding vaccination and community vaccine resources. Project Setting and Population Morgan County Satellite Clinic. Morgan County is a small rural county in Northern Utah with a population of 12,124 (United States Census Bureau, 2019a). The county is highly educated, with 98% of the adult population having earned a high school degree or higher. The mean income is $20,000 above the state average, with a low poverty rate of four percent. The LOW VACCINATION RATES 15 community is 94% Caucasian (United States Census Bureau, 2019a). Morgan County receives vaccine services from the Weber-Morgan County health department (WMHD) (Weber-Morgan Health Department, n.d.). The primary health department facility is located in Ogden City, which is more than a 30-minute drive for some Morgan County residents. Full vaccine services are offered by appointment, Monday through Friday. Twice a month, WMHD provides vaccine services in Morgan County. Prior to project implementation, the satellite clinic was available by appointment at the Morgan City building on the first and third Wednesdays of the month, 9 a.m. until 12 p.m. and 1 p.m. until 4 p.m., respectively. The satellite clinic was poorly utilized (C. Andreasen, personal communication, June 4, 2020). Aside from health department services, there is only one health center in Morgan County (Morgan Health Center, n.d.). The clinic has three providers, including one physician and two physician assistants. The clinic does not participate in the Vaccines for Children (VFC) program (UDOH, 2016). According to state legislation, certain vaccines are required to register for kindergarten through 12th-grade school, Headstart programs, or childcare facilities (Utah State Legislature, 2019). If parents choose not to vaccinate their child, Utah law allows for vaccine exemptions for medical, philosophical, or personal reasons (Utah State Legislature, 2019). Morgan County School-Aged Children. In Morgan County, 35% of the population is under 18 years of age (United States Census Bureau, 2019a). 93.1% of the population under 65 has health insurance, compared to the 89.5% state average (United States Census Bureau, 2019b). There are five public schools in Morgan County, including two elementary schools, two middle schools, and one high school that serve 3,103 students (Public School Review, 2020). In 2019, only 69.6 % of Morgan County seventh graders were adequately immunized compared to 89.2% of Weber County seventh graders and 90.3% of Utah seventh-graders overall (UDOH, LOW VACCINATION RATES 16 2019). Also, 16.2% of Morgan County seventh graders were granted exemption from vaccination for personal, religious, or medical reasons, compared to an exemption rate of 3.5% for 7th graders in Weber School district (UDOH, 2019). Morgan County was ranked as having the tenth highest rate of nonmedical exemptions in the nation (Olive et al., 2018). Gap of Vaccination Coverage in Morgan County School-Aged Children Low vaccination rates of Morgan County children can place individuals at risk for contracting vaccine-preventable illnesses. Factors of vaccine hesitancy such as the inconvenience of access, poor confidence in vaccines, and complacency towards vaccine-preventable illnesses contribute to this problem (WHO, 2014). Vaccination rates may be improved by addressing the driving factors of vaccine hesitancy through a multifaceted, tailored approach. Increasing accessibility of the Morgan County satellite clinic, providing a community media and incentive program, and developing vaccine and vaccine resources educational material are strategies that the DNP project employed to improve vaccination rates. Project Implementation Role of the DNP-FNP Leader Transformational leadership is an effective leadership style utilized when implementing this practice change (Porter-O’Grady & Malloch, 2018). Transformational leaders aim to create a vision of change, seek innovative ideas, implement evidence-based strategies, and strive to achieve set goals (Zaccagnini & Pechacek, 2021). For this project, in implementing change through communication and education, a vision of change was developed with stakeholders, including parents, students, the health department, and school employees. A significant portion of this project involved finding innovative solutions to barriers that presented due to the COVID-19 pandemic. When barriers were identified, teamwork and collaboration were used to find LOW VACCINATION RATES 17 evidence-based solutions and still addressed the project outcomes and the overall goal of increasing vaccination rates. DNP Project Plan The DNP lead project included a multifaceted, tailored approach to increase vaccination rates by addressing various causes of vaccine hesitancy. A multifactorial strategy is an effective way to address vaccine hesitancy, as a single component plan is not adequate for the complexities of vaccine hesitancy (WHO, 2014). This approach integrates the model of the 3C’s of vaccine hesitancy that describes the interaction of all three factors of the convenience of access, complacency, and confidence in contributing to vaccine hesitancy. The first objective of the plan was to improve the convenience of access of the Weber-Morgan County satellite vaccine clinic for Morgan County school-aged children. This objective was a high priority since a significant distance to full-time vaccine services causes access to vaccines to be very inconvenient for Morgan County students (Mead, 2019). Previously, the satellite clinic was primarily open during school hours. The literature supports changing vaccine clinic hours of operation to more convenient times to increase vaccination rates (Stinchfield, 2008). After receiving an exemption from the institutional review board (IRB), the first step in increasing accessibility was coordinating with WMHD to change the clinic hours of operations to times more convenient for Morgan County school-aged children. To increase accessibility for students, a convenience sample of Morgan County parents was surveyed on the community Facebook page Morgan Moms to determine the most desirable days (See Appendix A). Fridays and Mondays were the top two days selected. Friday received the highest number of votes at 40 votes, Monday followed at 16 votes, and only one vote was received for the current clinic day of Wednesday. The survey made evident that the current clinic day was not a desirable day for the LOW VACCINATION RATES 18 clinic to be held. The first Monday of the month, which included afterschool hours, and the third Friday morning of the month were selected as the new clinic schedule. WMHD made these changes, including posting the new schedule to their website. Convenience also includes having information that is easily accessible regarding the vaccine services (WHO, 2014). To provide this information, the availability of these services was communicated through various formats. First, posters were created and displayed at each of the five schools in the county and five places throughout the community. Posters included information about the new hours and days of operation of the satellite clinic, the location of the clinic, types of insurance accepted, how to make an appointment, the availability of free vaccines through the VFC program, and other information that increased awareness of the vaccine services available. An informational electronic flier was also produced with similar content that was to be emailed home to parents from their respective schools (see Appendix B). The flier was provided to the five schools in the district. The flier was also distributed at several COVID-19 mass vaccination clinics that WMHD held in Morgan County. The second project objective was to decrease vaccine complacency through a marketing and incentive program. Incentive programs are effective tools that can be implemented to increase motivation to vaccinate and improve vaccination rates (WHO, 2014). Inherent in vaccine complacency is a decision to put off the acceptance of vaccination to attend to other life or health responsibilities if vaccination is deemed to be less urgent (WHO, 2014). The media campaign aimed to produce a sense of urgency through the school posters, electronic fliers, and community fliers. Messages such as “Don’t wait, vaccinate” and “Vaccines save lives” are examples of urgent messages that the media campaign included. For the incentive program, nurses at the satellite clinic gave a coupon for a free doughnut from a local grocery store for LOW VACCINATION RATES 19 students that received a vaccine at the satellite clinic. Further, families were entered into a drawing to win a $25 grocery store gift card. Two separate drawings were held during the project implementation. These incentives were promoted in the media content. The literature supports that even small incentives can help increase motivation and vaccination rates (CPSTF, 2015). The third objective was to distribute educational material that included positive messages of vaccination and messages about the safety of community vaccine services to increase confidence in vaccines and the satellite clinic. The literature suggests that using just one or two vaccine messages can incite thoughts of vaccine acceptance (WHO, 2014). Additionally, research supports that using positive messages effectively safeguards against anti-vaccine messages (Wong, 2016). The positive and simple statement of “vaccines save lives” was included in the media campaign. The media campaign also had that COVID-19 precautions were being taken to provide a safe place to receive vaccinations during the pandemic. These messages were provided to both parents and students. By also providing education directed to the students through posters displayed at school, it was intended that students would gain a desire to be vaccinated or reminded of the need to be vaccinated and share this with their parents. School-based vaccine education has shown positive effects of decreasing vaccine concerns for students and increasing vaccination rates (Grandahl et al., 2016). Furthermore, student vaccine education may ensure that vaccine acceptance is developed now and maintained in the future as parents, creating a sustainable change (WHO, 2014). Evaluation and Data Analysis Data collection To assess the impact of the DNP project on the overall goal of improving vaccination rates in Morgan County school-aged children, outcome, process, and utilization measures of the LOW VACCINATION RATES 20 project were evaluated through surveys, observation, and chart reviews (Finkelman, 2018). The outcome measures examined included increased accessibility of the satellite clinic, implementation of an effective media and incentive program, and effective vaccine education and vaccination services information. A four-question survey, which contained multiple choice and open comment responses, was administered to parents that utilized the satellite clinic (see Appendix D). A three-question survey was administered over social media on the Facebook page Morgan Moms (see Appendix E) to determine if the DNP project achieved these specified outcomes. A third survey was administered to stakeholders in the WMHD (see Appendix F), such as the directors of the immunization program, nursing personnel, and the publicity information officer. This four-question survey utilized a Likert scale and open-ended questions that assessed the stakeholders’ perception of the appropriateness of the project plan, the probability of using the program in the future, and the utilization of teamwork and collaboration throughout the project. To examine process measures, the following were recorded during the project implementation period of January 1, 2021, through May 31, 2021: the number of schools that distributed the parent electronic flier; fliers distributed in the community; social media posts posted; posters displayed at the schools; and incentives given out. To evaluate utilization measures, the number of vaccines administered at the satellite clinic to children 18 years old or younger during the project was recorded from the health department’s electronic database at the project’s conclusion. Data Analysis and Results Descriptive statistics were utilized to quantify the results of the two parent surveys, the stakeholder survey, and the data collected on the number of vaccines administered at the satellite LOW VACCINATION RATES 21 clinic. For the surveys, ordinal data from the questionnaires were analyzed using frequency distribution with mode identification of the responses. Further, for the surveys that contained an open comment question, themes were developed from the comment responses. For vaccine and vaccine services promotion, posters were displayed at 100% (N=5) of the Morgan School District schools, including two elementary schools, two middle schools, and one high school. Twenty percent (n=1) of the schools emailed the parent flier to parents. Fliers were displayed on five community boards, such as at grocery stores and gas stations. One social media post was posted to the Morgan Moms Facebook page. As an adaption to Covid-19 barriers, 80 fliers were distributed at a Covid-19 vaccination clinic in place of social media posts. Incentives were given to 100% (N=6) of children that received vaccines at the satellite clinic. According to the WMHD database, a total of 17 vaccines were administered to persons 18 years or younger during the project implementation period at the Morgan Health Department clinic; as opposed to only one vaccine was administered during the same period in 2020, and two vaccines were administered during the same period in 2019 (see Appendix C). This is an 800% (n=16) increase from 2020 and a 750% (n=15) increase from 2019 (pre-pandemic). Responses from parents of the six children that received vaccines at the satellite clinic (N=4), when asked what type of promotion was most helpful in providing them with information about the Morgan Health Department clinic (with the option to choose three), 75% (n=3) answered social media, 50% (n=2) answered the WMHD website, 25% (n=1) answered the parent flier emailed from the school, 25% (n=1) answered posters displayed at schools, and 75% (n=3) answered other. Other fill-in responses included “word of mouth,” “from a friend at the health department,” and “the state coronavirus website.” When asked what encouraged them to vaccinate their child at the clinic (with the option to choose three), 100% (n=4) answered LOW VACCINATION RATES 22 convenience of a clinic in Morgan County, 50% (n=2) answered after school hours, 50% (n=2) answered reminders of the clinic hours/services from clinic promotion, and 50% (n=2) answered other, which included responses of “medical journals,” and “felt safer to go to a place with fewer people with Covid around.” The third question asked about the ease of vaccinating their child that day. Seventy-five percent (n=3) answered very easy, and 25% (n=1) answered neutral. Comments for the free-response question of “Is there anything that would make it easier for you to vaccinate your child at this clinic, or to vaccinate your child in general?” included positive messages such as “everything is perfect for me,” “no,” and “I like mass clinics.” A convenience sample was obtained for the survey posted to Morgan Moms Facebook page (N=40) (see Appendix E for survey questions and results). Sixty-three percent (n=25) answered that they were unaware of the health department vaccine clinic in Morgan, and 38% (n=15) selected that they knew about the clinic. Of those that were aware of the clinic, 47% (n=7) answered that they heard about the clinic from the parent email from the school, 20% (n=3) from social media, 13% (n=2) selected other, and 7% (n=1) selected the WMHD website, posters displayed at school, community fliers, or word of mouth. When asked which of these promotional methods are most helpful for receiving information about the satellite vaccine clinic (with the option to choose two), answers included: 69% (n=27) parent email, 69% (n=27) social media, 28% (n=11) community fliers, 13% (n=5) word of mouth, 7% (n=3) school posters, and 7% (n=3) WMHD website. Overall, responses from the online parent survey and the survey administered at the satellite clinic demonstrated that parents prefer to receive information about immunizations from social media and electronic communications from the schools. Further, the convenience of services located in Morgan, receiving reminders about services offered, and having afterschool hours supported vaccination. LOW VACCINATION RATES 23 For the stakeholder survey, there were four respondents (N=4) (see Appendix F for survey questions and results). One hundred percent (n=4) selected agree or strongly agree with the statement “The project plan appropriately addressed low vaccination rates in Morgan County school-aged children,” 100% (n=4) selected agree or strongly agree with the statement “I am likely to use aspects of this routine vaccination plan in the future.” For the third question, 100% (n=4) selected strongly agree with the statement, “The DNP student used teamwork and collaboration during the project process.” For free-response comments for the final question of “What suggestions do you have for a future project to address low vaccination rates in Morgan County school-aged children?” themes centered around continued efforts to increase clinic awareness and provide further vaccine education to the community. Further, a free comment was made of “in a non-pandemic year, I think this plan is solid.” Survey respondents recommended no changes to the plan, but acknowledgment was made of the pandemic’s challenges to addressing vaccination rates of routine vaccines. Discussion, Recommendations, and Conclusions Discussion This DNP lead project sought to implement a plan that addressed low vaccination rates of school-aged children in Morgan County, Utah. The results of this project suggest that a tailored, multifaceted plan effectively improved vaccination rates by addressing vaccine hesitancy. Increased vaccinations administered at an under-utilized satellite clinic in Morgan County was achieved. Nationally, vaccination rates of routine vaccines in children markedly declined during the pandemic (Ackerson, 2021). Increasing the number of vaccines given during this period as national vaccination rates declined indicates significant improvement. LOW VACCINATION RATES 24 Vaccine hesitancy is a complex phenomenon influenced by convenience, complacency, and confidence that the project’s plan individually addressed. Surveyed parents conveyed that the convenience of the clinic being available in Morgan County was one of their top reasons for utilizing the clinic. The availability of afterschool hours and reminders about clinic services were the second-highest responses, which are other aspects of convenience. The survey substantiates that these were important and influential elements to parents and should be considered in future vaccination projects. Although incentives and vaccine messages were not selected as top reasons for vaccinating their children at the satellite clinic, which were included in the project to address complacency and confidence, a larger sample may have demonstrated the importance of those aspects as well. Also, due to communication limitations from Covid restrictions, such as not being able to promote the project on social media, the respondents may not have been exposed to those aspects of the project before choosing to vaccinate at the satellite clinic. Another aspect of the project included providing impactful promotion of vaccines and vaccine services to address confidence. Surveyed parents reported the school emails and information shared over social media were very helpful in providing awareness of vaccine services in Morgan. Limitations and Lessons Learned Covid-19 presented some limitations of fully implementing the project as initially planned. The pandemic created hesitation at the school level and the health department regarding sending out information regarding routine vaccines because parents were currently looking for Covid-19 vaccine information. There was concern that this may create confusion. As a result, social media posts were not posted to the health department’s Facebook page, and the schools did not all send out the electronic flier to parents. Other methods of vaccine promotion were able to be used instead, such as distributing fliers at Covid-19 vaccine clinics. However, a larger LOW VACCINATION RATES 25 audience would have been reached if social media and the school email could have been fully utilized. Working more closely with these entities regarding the information to be sent out may have allowed further use of school and health department communications. Although communication was limited, parents’ preferences for these communication methods were identified. This information may be useful in the future during non-pandemic circumstances when social media and school parent emails will be more freely available to utilize for vaccine promotion. With expanded access to social media and school emailing in the future, it would be likely that the awareness of the satellite clinic services would significantly increase, and parents would more often utilize the clinic. Despite the project’s limitations in implementing the original plan, important sustainable changes were made. The clinic’s schedule was changed to times more convenient for school-aged children. This is a change that will continue beyond the duration of the project. Post-project survey results supported this change, and this finding cannot be undervalued when addressing low vaccination rates. Recommendations As vaccine hesitancy is a significant barrier to achieving desired vaccination rates, vaccine hesitancy should be meticulously addressed in vaccination efforts. A tailored, multifaceted approach is necessary for this complex problem to attain significant improvement (WHO, 2014). The findings of this project add to the body of knowledge of the importance of addressing the factors of vaccine hesitancy when aiming to increase vaccination rates. Although vaccine hesitancy is often thought of as a lack of confidence in vaccines, the other aspects of convenience and complacency must not be ignored (WHO, 2014). Addressing one factor but neglecting to address the others will limit results. This approach to vaccine hesitancy can be LOW VACCINATION RATES 26 applied to a population-based practice change or at the individual level as a DNP family nurse practitioner. Addressing the factors of vaccine hesitancy at the personal level too can yield increased vaccination. Improved vaccination rates elevate both individual health and the health of a community (Messonnier, 2019). When high vaccination rates are achieved, herd immunity protects those medically unable to be vaccinated or experiencing waning immunity (Messonnier, 2019). Further, herd immunity protects against disparities of access to vaccine services and access to primary care resources in general, as herd immunity protects vulnerable populations with poor health care access against dangerous vaccine-preventable diseases. Striving to decrease vaccine hesitancy as a DNP family nurse practitioner provides vital protection to these vulnerable populations. Although there were challenges of implementing this project during the pandemic, as vaccine efforts for the Covid-19 vaccine encounter vaccine hesitancy difficulties, the principles may be applicable of addressing the factors of vaccine hesitancy. Convenience, complacency, and confidence are universal factors of hesitation towards vaccine acceptance and may be effective in increasing acceptance of the Covid-19 vaccine and other new vaccines developed in the future. Conclusions Although the safety and effectiveness of routine vaccines have been demonstrated, some are reluctant or refuse to vaccinate (WHO, 2014). This trend of vaccine hesitancy has been steadily increasing (Williams, 2019). Vaccine hesitancy is a complex phenomenon that encompasses inconvenient access, complacency towards vaccination, and a lack of confidence in vaccines or vaccine services (WHO, 2014). The literature suggests that a tailored, multifaceted LOW VACCINATION RATES 27 approach that addresses factors of vaccine hesitancy in identified pockets of low vaccination, such as Morgan County, Utah, can be an effective method to increase vaccination rates (WHO, 2014). To address low vaccination rates of school-aged children in Morgan County, Utah, these factors were addressed in a population-focused practice change DNP project by increasing accessibility of the WMHD vaccine clinic, providing a media and incentive program, and distributing vaccine and vaccine services promotional material. As a result, utilization of the WMHD vaccine clinic increased, and project outcomes were achieved. The DNP leader used teamwork and collaboration in project planning, implementation, and project revision as obstacles were encountered, relying on evidence-based practice and principles of patient-centered care. As vaccination rates of school-aged children improve in Morgan County, it will not only provide means of protection from illness and death, but vaccines also can close the gaps of health disparities, protect those that are medically unable to receive vaccines through herd immunity, and overall improve quality of life (Messonnier, 2019). 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Burlington, MA: Jones & Bartlett Learning. LOW VACCINATION RATES 36 Appendix A Preferred Clinic Day Survey LOW VACCINATION RATES 37 Appendix B Project Flier LOW VACCINATION RATES 38 Appendix C Vaccines Administered at the Satellite Clinic Figure D1. Vaccines administered at the Morgan satellite clinic during project implementation (January 2021 – May 2021) compared to previous years during the same time of year. LOW VACCINATION RATES 39 Appendix D Parent Survey of Children Vaccinated at the Satellite Clinic Figure E1. Question 1: What type of advertising was most helpful in providing you information about the Morgan vaccine clinic services? (Up to three could be selected.) Other responses included “word of mouth,” “from a friend at the health department,” and “the state coronavirus website.” Figure E2. Question 2: What encouraged you to vaccinate your child at this clinic? (Up to three could be selected.) Other responses included “felt safer to go to a place with fewer people with covid around” and “medical journals.” LOW VACCINATION RATES 40 Figure E3. Question 3: Overall, how easy was it to vaccinate your child today? LOW VACCINATION RATES 41 Appendix E Social Media Parent Survey Figure F1. Question 1: Are you aware that the Weber-Morgan Health Department has a routine vaccine clinic in Morgan (offering school and flu shots)? Figure F2. Question 2: If yes for #1, how did you hear about the Morgan vaccine clinic? If no, skip to #3. (All that apply could be selected.) LOW VACCINATION RATES 42 Figure F3. Question 3: Of the promotional methods listed above, which methods are most helpful for you to receive information about the Morgan vaccine clinic? (Up to two could be selected.) LOW VACCINATION RATES 43 Appendix F Survey of WMHD Stakeholders Table G1 Survey Question Strongly Disagree % (n) Disagree % (n) Neutral % (n) Agree % (n) Strongly Agree % (n) The project plan appropriately addressed low vaccination rates in Morgan County school-aged children. 0% (0) 0% (0) 0% (0) 25% (1) 75% (3) I am likely to use aspects of this routine vaccination plan in the future. 0% (0) 0% (0) 0% (0) 25% (1) 75% (3) The DNP student used teamwork and collaboration during the project process. 0% (0) 0% (0) 0% (0) 0% (0) 100% (4) Note. After completing the DNP project, key stakeholders at WMHD were surveyed to assess their satisfaction with the project plan, the implementation of the program, and the ability of the DNP student to use teamwork and collaboration throughout the project. All of those surveyed provided positive responses to the surveyed questions.