Digital Repository Doctoral Projects Spring 2022 Improving Vaccination Rates on a University Campus Katherine T. Jenkins Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Jenkins, K.T. (2022) Improving Vaccination Rates on a University Campus Weber State University Doctoral Projects. https;//dc.weber.edu/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 on a University Campus by Katherine T. Jenkins 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 April 29, 2022 ______________________________ Date _______________________________ ______________________________ Kristy A. Baron, PhD, RN Date DNP Project Faculty _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: This form and paper must be submitted by the program director. April 29, 2022 April 29, 2022 _______________________________ Katherine Turley Jenkins, DNP, APRN, FNP-C April 29, 2022IMPROVING VACCINATION RATES Table of Contents Improving Vaccination Rates on a University Campus .................................................................. 2 Background and Problem Statement ........................................................................................... 2 Diversity of Population and Project Site ..................................................................................... 3 Significance for Practice Reflective of Role-Specific Leadership ............................................. 4 Framework and Literature Review ................................................................................................. 5 Framework .................................................................................................................................. 6 Unfreeze .................................................................................................................................. 6 Change .................................................................................................................................... 6 Refreeze .................................................................................................................................. 7 Synthesis of Literature ................................................................................................................ 7 Search Methods ....................................................................................................................... 8 Vaccines .................................................................................................................................. 8 Vaccine-Preventable Communicable Diseases ................................................................... 8 Vaccination Rates Among Adults ....................................................................................... 9 Barriers to Vaccination ........................................................................................................... 9 Vaccine Perceptions and Attitudes ..................................................................................... 9 Vaccine Hesitancy ............................................................................................................ 10 Access ............................................................................................................................. 101 Vaccines in Young Adults .................................................................................................... 12 Vaccine Perceptions Affecting Immunization Rates ........................................................ 12 Discussion ................................................................................................................................. 13 Implications for Practice: Vaccine Education Intervention for College-Age Adults ............... 13 Project Plan ................................................................................................................................... 14 Project Design ........................................................................................................................... 14 Needs Assessment of Project Site and Population .................................................................... 14 Cost Analysis and Sustainability of Project .............................................................................. 15 Budget ................................................................................................................................... 15 Sustainability......................................................................................................................... 16 Project Outcomes ...................................................................................................................... 16 Consent Procedures and Ethical Considerations....................................................................... 17 Instrument to Measure the Effectiveness of Intervention ......................................................... 17 Project Implementation ................................................................................................................. 18 Intervention ............................................................................................................................... 18 IMPROVING VACCINATION RATES Online Vaccine Educational Module Developed by Experts ............................................... 18 Description of Online Educational Module .......................................................................... 19 Vaccine Module Implemented in the First-Year Experience Classes .................................. 20 Alignment of Project Interventions With Short-term Outcome and Overall Outcome ........ 20 Project Timeline ........................................................................................................................ 21 Project Evaluation ......................................................................................................................... 21 Data Maintenance/Security ....................................................................................................... 21 Data Collection and Analysis.................................................................................................... 22 Quantitative Data .................................................................................................................. 22 Qualitative Data .................................................................................................................... 24 Findings..................................................................................................................................... 26 Strengths ............................................................................................................................... 26 Weaknesses ........................................................................................................................... 27 Quality Improvement Discussion ................................................................................................. 28 Translation of Evidence Into Practice ....................................................................................... 28 Implications for Practice and Future Scholarship ..................................................................... 28 Sustainability......................................................................................................................... 29 Dissemination ....................................................................................................................... 29 Conclusion ................................................................................................................................ 30 References ..................................................................................................................................... 31 Appendix A ................................................................................................................................... 36 Appendix B ................................................................................................................................... 37 Appendix C ................................................................................................................................... 38 Appendix D ................................................................................................................................... 40 Appendix E ................................................................................................................................... 41 Appendix F.................................................................................................................................... 43 Appendix G ................................................................................................................................... 44 Appendix H ................................................................................................................................... 45 Appendix I .................................................................................................................................... 46 IMPROVING VACCINATION RATES 1 Improving Vaccination Rates on a University Campus Purpose: A need for increased vaccination uptake among college-age adults exists to stop vaccine-preventable infectious disease outbreaks on campus. The goal of this DNP project was to decrease vaccine hesitancy among college-age students at Weber State University by implementing an online vaccine module educating first-year experience (FYE) students about the importance of vaccines in preventing outbreaks of infectious diseases. Methodology: FYE students completed a background information survey and pre- and post-intervention surveys to assess sociodemographic information and vaccine hesitancy and knowledge. These surveys contained multiple response methods, including the Likert scale and free-text box options. Both quantitative and qualitative data were collected during the module intervention. Results: Data analysis showed decreased vaccine concerns related to side effects and increased vaccination knowledge among the participants, including increased students’ expectations of others to be up to date on vaccinations. The intervention increased the overall understanding of communicable diseases, purpose of vaccines, creation of vaccines, and recommendation of vaccines as a primary prevention measure. Implications for practice: Outcomes show that vaccine knowledge did increase while vaccine hesitation in some areas decreased. Additionally, the education module can be adapted and updated to fit current student needs, including future information regarding COVID-19 and associated vaccines. Project findings support the continued use of the education module at Weber State University. Keywords: adult immunizations, college students, immunization, vaccination rates, vaccine attitudes, vaccine hesitancy IMPROVING VACCINATION RATES 2 Improving Vaccination Rates on a University Campus Vaccines are fundamental aspects of preventative medicine, and their use has eradicated and significantly minimized the spread of many communicable diseases, which previously caused substantial morbidity across the United States (Orenstein et al., 2005). Remy et al. (2015) report that vaccines prevent approximately three million deaths each year worldwide. Implementation of childhood vaccination schedules across the United States has dramatically decreased disease in children 18 years and younger; however, the same cannot be said for adults (Tan, 2014). Unfortunately, many adults, particularly young adults, have minimal knowledge regarding vaccine use, benefits, and schedule recommendations. This lack of knowledge leads to under-vaccinated or unvaccinated adults, further causing concern for increased outbreaks of vaccine-preventable communicable diseases. The purpose of this project is to review the literature outlining the need for increased vaccine uptake among young adults, recommend a program to educate first-year experience (FYE) students about immunization importance, implement this program as a doctor of nursing (DNP) project, and evaluate the effectiveness of the project by assessing FYE students' knowledge of vaccine benefits to support vaccine uptake in this population. Background and Problem Statement Numerous outbreaks of vaccine-preventable communicable diseases on college campuses have occurred in recent years. Barraza et al. (2019) and Sandler et al. (2019) report significant increases in meningitis and mumps outbreaks on college campuses across the nation. Barraza et al. (2019) report that higher education institutions' varying vaccine recommendations and requirements have led to significant outbreaks of previously nearly eradicated vaccine-preventable communicable diseases. A decrease in young adult vaccination rates affects IMPROVING VACCINATION RATES 3 population safety. Safety should be a primary goal of any educational institution. Student safety is jeopardized when on-campus students of higher education institutions are not adequately vaccinated and put other students, faculty, staff, and community members at risk for vaccine-preventable diseases. A particular need for immunization improvement among college-age adults exists to decrease or eliminate vaccine-preventable disease outbreaks on college campuses. Diversity of Population and Project Site The American College Health Association (2018) states that outbreaks on college campuses can cause significant disruption and a financial and emotional burden to everyone involved, including students, professors, peers, and family members. Increased vaccination uptake may be a viable solution for this problem. Remy et al. (2015) report that vaccines provide many public health benefits, including minimizing or eliminating vaccine-preventable diseases; improved economic outcomes with decreased funding spent on vaccine-preventable disease healthcare; and reduced morbidity and mortality. These benefits can improve population health both on and off-campus. Many universities do not require vaccinations before admission or enrollment in classes. Lack of vaccination requirements among young adults has led to the outbreak of many vaccine-preventable communicable diseases, previously nearly eradicated (Barraza et al., 2019). Higher education institutions are responsible for creating a safe living and learning environment for college students by improving vaccine knowledge and access. Barraza et al. (2019) show that though higher education institutions focus on student safety regarding guns, drugs, and various other threats, they do not discuss the threat to public health that occurs when unvaccinated or under-vaccinated students are allowed to attend and even live on campus. Enhancement of the IMPROVING VACCINATION RATES 4 on-campus learning environment includes health and well-being for students, faculty, and staff. Improving vaccination knowledge and vaccine uptake can contribute to this enhancement. Acknowledging barriers to young adult immunization and creating plans to improve immunization rates remain essential, specifically among the first-year students attending higher education institutions. In 2018, the Utah Scientific Advisory Vaccine Committee, working with the Utah Board of Higher Education, updated policies to educate on-campus college-age students about vaccines and communicable diseases. According to the Utah System of Higher Education (2018), this policy states that all on-campus housing students must be provided education regarding vaccine-preventable communicable diseases at the time of admission or enrollment. This policy requires a change in Weber State University's (WSU) campus requirements. The vaccine education mandate and the need to implement a vaccine education module are the foundation for this DNP project. Significance for Practice Reflective of Role-Specific Leadership This DNP project aims to improve safety and enhance the student experience by increasing vaccine education in FYE students to decrease the potential of vaccine-preventable diseases. The post-master's DNP leadership role is vital to the project's success. Many DNP leadership skills are used, such as collaboration and effective communication among stakeholders, DNP leader, and other project team members. Leadership by role modeling is crucial for effective communication and learning (Marcy et al., 2019). A DNP leader who respects others, proves trustworthy, and possesses confidence has more effective outcomes (Reavy, 2016). These attributes and critical thinking are vital in managing any problems or complications throughout the project process. These leadership skills can further support project IMPROVING VACCINATION RATES 5 outcomes of enhancing the student experience, improving population health, reducing cost, and meeting the state of Utah vaccine education mandate. Framework and Literature Review Vaccines are effective in eradicating communicable diseases worldwide. The Centers for Disease Control (CDC, 2012) states that a vaccine is a type of medication made with weakened or killed germs that cause significant disease. Vaccines provide immunity when exposure to disease-containing serum stimulates the immune system to produce antibodies as if exposed to the virus or bacterium. Some vaccines are administered orally, while most are administered by injection. Vaccinations protect everyone, not just those who receive them, by herd immunity or community immunity (Pan, 2017). Community immunity is when enough individuals receive disease-specific vaccinations preventing the further spread of these diseases to others within the community who have not been vaccinated or have not had prior disease exposure (CDC, 2020). Those who cannot be immunized, such as the very young and those who are immunocompromised, benefit dramatically from community immunity. Laws governing vaccination have been implemented to improve public health and provide continual community immunity, particularly the requirement of specific vaccinations before entering school (Pan, 2017). Unfortunately, research shows that new generations of under-vaccinated or unvaccinated individuals have decreased community immunity and increased communicable disease outbreaks. The purpose of the literature review is to identify common themes and causes of increased communicable disease outbreaks, vaccine attitudes and hesitancy, and the need for increased vaccination uptake. IMPROVING VACCINATION RATES 6 Framework When considering a DNP project and implementing change in healthcare, many theories can be applied to make the change permanent and effective. Synthesis of the literature is also vital to understanding the change itself. Lewin's theory of planned change is an excellent way to establish change permanence within an organization. The DNP nurse leader can apply this theory after identifying a problem or need for change. A solution or intervention for the change is then created and executed, and the implemented change becomes permanent (Shirey, 2013). The three critical elements of Lewin's theory are unfreezing, change, and refreezing, which can be applied specifically to this DNP project. Unfreeze The change process is a vital component to the success of the DNP project. When applying Lewin's theory of planned change, the necessary change identified in the unfreezing process is increasing vaccine uptake on the WSU campus. Increased vaccine uptake among students can promote population health, decrease vaccine-preventable disease outbreaks, and reduce healthcare costs. Another purpose of this project implementation is to meet the state requirement for a university immunization education module outlined by the Utah Board of Higher Education, putting the University in compliance with the mandate. Change When considering the need to increase vaccination uptake on a university campus, the proposed change includes implementing a campus-wide vaccination campaign and education module. Sandler et al. (2019) report the need for campus health services to educate students to increase vaccine knowledge and improve vaccination uptake in young adults. While campus health services may play an integral role in supporting the change, other departments can also IMPROVING VACCINATION RATES 7 contribute. Integrating the educational module as part of the first-year freshman experience allows for change sustainability. However, campus-wide vaccine education access for all students, not just those participating in FYE courses, would help capture a larger adult population, increasing overall vaccine education and potential vaccine uptake rates. Refreeze Once the vaccine campaign and education module's implementation has occurred, it is essential to note that the planned change is not complete. The final step in Lewin's theory is to finalize the concept of refreezing. Refreezing includes continued efforts to regularly incorporate the vaccine education module with all incoming students each semester as an ongoing requirement. This action requires collaboration with the freshman studies department to include it in every semester's FYE courses or transition module implementation to another department on campus. Support from the FYE director and other departments may be needed to make administrative changes necessary for change permanence. Moreover, student health services and campus administration may also play a significant role in student vaccination sustainability and continued education. Synthesis of Literature Critical appraisal of the literature is vital to translate evidence into best practice and support the need for change. Many common themes emerge when assessing vaccine literature, including vaccine hesitancy, attitudes, and perceptions. The synthesis of this literature supports these themes and shows gaps in vaccine education among adults. Behavioral determinants such as lack of access, cost, and insufficient knowledge are also evident. IMPROVING VACCINATION RATES 8 Search Methods Studies and articles were researched and collected to determine current vaccination issues and support increased vaccine uptake among adults. Specific search terms included adult immunizations, college students, immunization, vaccination rates, vaccine attitudes, and vaccine hesitancy. Searched databases include OVID, CINAHL, Elsevier, Medline, and Cochrane. A total of 23 primary sources were found with inclusion criteria of studies and articles discussing adult immunization, communicable disease outbreaks on college campuses, vaccine hesitancy, and attitudes. Publications ranged from 2005 to 2020, and older publications were excluded from the review. Additional exclusion criteria included literature that focused solely on infants and young children. Evidence level I to VII studies were included in the literature review, such as meta-analysis, experimental, non-experimental, and qualitative designs. Vaccines Vaccine-Preventable Communicable Diseases. Many vaccine-preventable communicable diseases still occur across the United States. These diseases include measles, mumps, pertussis, human papillomavirus, varicella, influenza, and others. According to statistics from the Utah Department of Health (2020), in 2012, there were more than 1,500 new cases of pertussis in Utah that affected people of all ages. The CDC (2017) supports these findings by reporting that across the United States, in that same year, there were approximately 48,277 new cases of pertussis. Additionally, the American College Health Association (2018) reports that the increase in vaccine-preventable communicable diseases is likely due to a lack of immunization and increased international travel. A qualitative analysis by Calugar et al. (2006) found that this increase in outbreaks shows decreased community immunity, leaving individuals who cannot be IMPROVING VACCINATION RATES 9 vaccinated unprotected from these diseases, resulting in costly medical care for illnesses that could have been prevented. According to the editorial by Pan (2017), the lack of immunization and increased vaccine-preventable communicable disease outbreaks endangers public health and can lead to a crisis. Vaccination Rates Among Adults. Vaccination rates among adults are significantly less than in children. The non-experimental survey study by Kempe et al. (2011) found that while the implementation of vaccine schedules and immunization campaigns have shown a decrease of nearly 100% morbidity among children, the same cannot be said for adults. Tan (2014) supports this finding, noting that the gap between adult vaccination rates and immunization goals is significant. This gap often produces a substantial increase in vaccine-preventable communicable diseases, causing an estimated 40,000 to 80,000 adult deaths each year. Many barriers affect vaccination rates in young adults, including vaccine perceptions and attitudes, vaccine hesitancy, and access. Barriers to Vaccination Vaccine Perceptions and Attitudes. Many adults have negative perceptions of vaccines regardless of how they benefit society. Johnson et al. (2019) performed a quasi-experimental randomized study finding that innate ideologies and conspiracy theories can significantly affect vaccine hesitancy. These deep-rooted beliefs are often learned from parents or peers and can be extremely difficult to change. Many of these beliefs arise from false information presented as research. Additionally, Chen et al. (2020) conducted an experimental, randomized control trial showing fabricated research such as the correlation between the measles, mumps, and rubella (MMR) vaccine and autism published by Wakefield, resulting in a media frenzy and growth of IMPROVING VACCINATION RATES 10 vaccine-related conspiracy theories. Though the study by Wakefield was retracted, many still believe vaccines cause autism, and subsequently, countless children and adults remain unvaccinated or under-vaccinated (Jadhav et al., 2018). Many similar findings are fabricated or exaggerated, making it difficult to undo the damage these sensational stories have caused and their effect on population immunization. The non-experimental survey study by Nyhan et al. (2012) found that social media has also played a significant role in affecting attitudes and beliefs about vaccination, particularly among college-age students. Vaccine perceptions have also led to many immunization waiver forms being completed for people of all ages. Jadhav et al. (2018) found no laws in the United States requiring individuals to be immunized; however, some institutions require immunizations for admittance, such as healthcare facilities, armed forces, and educational institutions. Unfortunately, the everyday use of vaccine waiver forms allows for continued disease outbreaks on college campuses. The correlational study (n = 4,098) by Navin et al. (2019) shows that immunization waiver forms allow people to refuse vaccination requirements for any of the following reasons: religious, medical, philosophical, or personal beliefs. Additionally, the article by Barraza et al. (2019) shows that acquiring vaccine exemption is often easier than proving vaccination status, resulting in increased numbers of non-vaccinated individuals who pose a potential threat to public health. Vaccine Hesitancy. Many variables contribute to vaccine hesitancy among adults over the age of 18. The qualitative meta-analysis by Nowak et al. (2015) found many common cognitive barriers to vaccination, including the perception that vaccine recommendations do not apply to the general population, vaccinations are not effective, fear regarding susceptibility to the disease after vaccination, and personal experience with the disease. These factors do not apply IMPROVING VACCINATION RATES 11 only to influenza but all vaccine-preventable communicable diseases. Moreover, Britt and Englebert (2018) showed that sociodemographic factors such as living in a rural community, low socioeconomic status, insufficient income, and gender identity also contribute to vaccine hesitancy. Furthermore, the practice guidelines developed by Taddio et al. (2015) demonstrate that individuals may also be hesitant or noncompliant with vaccination recommendations due to fear of needles or pain from vaccination injections. Access. Several system failures affect adult vaccination rates. In the research review by Tan (2014), these factors include adult minimization of immunization importance, lack of funding, inadequate access to healthcare services, insufficient education about immunization safety and efficacy, and confusion regarding adult vaccination schedules. As young adults bridge the gap from childhood to adulthood and begin to establish a life without parental oversight, they may face additional barriers. Another barrier to access includes behavioral determinants. The non-experimental descriptive study by Britt and Englebert (2018) examined behavioral determinants affecting vaccination intent among 208 rural and medically underserved college students. The study results showed that while normative beliefs and attitudes may be present, competing demands that take up significant time and attention, specifically work and school, affect vaccination attitudes and further prove the need for more education and support. Throughout the literature synthesis, these common themes among all demographics were noted, including lack of availability or access, inability to pay, and insufficient knowledge. The ease with which young adults can access healthcare may affect vaccination status. Additionally, lack of insurance, selection of primary care providers, and service locations can decrease vaccination access (Britt & Englebert, 2018; Kelly et al., 2014). IMPROVING VACCINATION RATES 12 Vaccines in Young Adults When compared to children, adults have significantly lower immunization rates (Tan, 2014). A cross-sectional quantitative study (n = 964) performed by Jadhav et al. (2018) and a qualitative research study by Sandler et al. (2019) demonstrated that young adults between 18-35 years of age are at an increased risk for exposure to and contracting vaccine-preventable communicable diseases due to their prevalence on university campuses. College students, particularly on campuses without vaccination requirements, are at higher risk for contracting vaccine-preventable communicable diseases due to shared living quarters and frequent close interactions with peers. These variables lead to the development of significant infectious disease outbreaks (Jadhav et al., 2018). Vaccine Perceptions Affecting Immunization Rates. Young adults have minimal vaccine experience, do not believe they need vaccinations, or are unaware of their vaccination status. Qualitative studies by Hilton et al. (2015) and Sandler et al. (2019) found that teenagers' limited experience with vaccine-preventable diseases has caused a lack of knowledge regarding vaccines and their importance. Additionally, low vaccination rates among older teens and young adults are likely due to perceptions of invulnerability and decreased perceived risks related to communicable diseases. Other variables affecting vaccine uptake include perceptions of vaccination applicability, effectiveness, sociodemographic factors, fear, and personal experience with vaccination. The meta-analysis by Nowak et al. (2015) found that these themes illustrate the need for increased education to improve young adults' knowledge, attitudes, and beliefs regarding vaccination. Sandler et al. (2019) performed a qualitative study (n = 33) by interviewing college-age students IMPROVING VACCINATION RATES 13 about vaccine knowledge. They found that most young adults lacked awareness of university vaccination requirements and had minimal understanding of general vaccine information. Discussion While there are many articles about vaccination, the vast majority focus on immunizations in children. While vaccination of children is of great importance, there are gaps in the literature about adult immunizations, particularly young adults. Some limitations in the evidence include small sample sizes in many studies. Other limitations include the reduced numbers of quantitative studies versus many editorials or expert opinion articles on the subject. The topic of adult vaccinations can greatly benefit from more extensive research and higher-level research studies to support increased vaccination among the general public. Implications for Practice: Vaccine Education Intervention for College-Age Adults Many vaccine-preventable communicable disease outbreaks occur across the United States, with an increase noted on university campuses. Vaccines effectively eradicate these diseases, but the lack of vaccination uptake among the population, particularly among young adults, remains a problem. Acknowledging the causes of vaccine hesitancy and barriers among young adults is essential to improve uptake by this population. Education about vaccine-preventable diseases can change vaccine attitudes and decrease vaccine hesitancy (Johnson et al., 2019). The evidence outlined in the research synthesis supports the need for increased vaccine education among adults. Educational modules can be incorporated through the first-year freshman experience as a required course section in higher educational institutions. The DNP project implementation of an FYE immunization module can increase vaccine education, knowledge regarding access and cost and impart the importance of immunizations to prevent outbreaks of vaccine-preventable communicable diseases on campus. IMPROVING VACCINATION RATES 14 Project Plan Project Design The DNP project design is a quality improvement practice intervention using e-learning technology. The goal of the quality improvement project is to increase vaccine education, possibly leading to increased vaccination rates on campus, improving educational experiences through significant in-person contact. The project and potential increased vaccination among these college-age adults further create a safe on-campus environment. The hope remains that using the vaccine education module in FYE courses leads to a vaccine policy practice change across the WSU campus. Needs Assessment of Project Site and Population The site for this quality improvement project is the Weber State University, Ogden campus. The specific site needs include stakeholder support and communication, particularly with the faculty and staff of the FYE department. The project team stakeholders comprise nurse leaders, WSU Academic Web Services webmasters, Utah Department of Health staff, and WSU faculty and administration. Understanding stakeholder roles and needs are vital to creating a solid team while establishing appropriate communication addressing project populations. Direct populations affected by this project include FYE instructors, the FYE director, and the WSU Web Services department. These stakeholders and DNP project team members have roles, including participation in the planning and implementation phase, supporting and promoting participant buy-in, and utilizing personal expertise for project intervention. The WSU web designers worked with nurse leaders to establish appropriate e-learning technology for hosting and adapting the module specifically for WSU students. This step includes assessing the previously developed vaccine e-learning module and working through the technological IMPROVING VACCINATION RATES 15 processes to update and adjust for WSU FYE courses. The faculty role involves implementing the vaccine module in FYE courses as part of the health unit. Indirect populations include all students enrolled in the FYE courses for the Fall 2021 semester. The student's role is to participate in all components of the vaccine education module. Participation includes viewing the introduction video and completing the background information and pre-module surveys, followed by the vaccine module with interactive media components and the post-survey. When assessing participant needs, it is vital to understand that many disparities and social determinants of health (SDoH) decrease vaccination status in college-age adults, which results in outbreaks of vaccine-preventable infectious diseases, affecting population health. Social injustices that may affect students include family, social, school, and work demands associated with their attitudes, subjective norms, and perceived behavioral control related to vaccination intent (Britt & Englebert, 2018). By addressing these SDoH, the implementation of this program as a quality improvement project enables the DNP student to evaluate the effectiveness of the project by assessing for improvement in FYE students' vaccine knowledge. Cost Analysis and Sustainability of Project Budget Currently, there are minimal fiscal requirements for this DNP project. The Utah Department of Health has provided the vaccine education module at no cost to the University or DNP Project Team. The WSU Academic Web Services department is transitioning the module and creating a new website to be hosted on the WSU server, requiring time budgets accounted for by the University. The FYE department is incorporating the module as part of its curriculum. Faculty training regarding the project intervention and pilot testing occurs in the FYE IMPROVING VACCINATION RATES 16 department, and time is budgeted accordingly. Creating the introductory video within the FYE department may be the only potential monetary cost. DNP project leaders may adjust budgetary needs throughout the project process as needed (see Appendix A). Sustainability Project sustainability is controversial at this time. While financial burdens related to this quality improvement project are minimal, both system and political realities affect the feasibility of project sustainability. Though the Utah Board of Higher Education mandate is specific to all on-campus housing students, there is controversy regarding the permanent addition of vaccine requirements for all university students, faculty, and staff. Implementing campus-wide vaccine requirements would require participation in the political arena, and currently, there is no one on campus willing to fulfill this role. Project Outcomes Short-term outcomes include the primary education of FYE students regarding vaccines regardless of SDoH, improving social justice in this population. Social justice concerns regarding health inequity lead to health disparities and related determinants that result in poor health access and care among marginalized or excluded populations (Curley, 2020). In college-age young adults, medically underserved populations in rural settings have reduced vaccination access and rates due to poor healthcare access and limited providers available to provide immunizations and education. In addition, increased uninsured individuals and higher poverty rates lead to poor vaccination status (Britt & Englebert, 2018). Realistically understanding and improving social justice in this population means assessing SDoH and establishing policies and interventions to enhance health equity to eliminate these disparities (Curley, 2020; Healthy People 2020, 2021). By addressing social justice concerns through improved education, vaccination rates can IMPROVING VACCINATION RATES 17 positively impact health equity and healthcare outcomes in the short and long term. Using instruments to measure participant data can assess project outcomes' realistic improvement and measurability within a few weeks. Consent Procedures and Ethical Considerations IRB approval was obtained via the WSU Institutional Review Board who confirmed that the DNP project meets the standard for a quality improvement project. The IRB does not require informed consent for student participation in the quality improvement project. The vaccine education module, including background information and pre- and post-module surveys, are completed by each student enrolled in WSU's FYE courses Fall semester of 2021. Students access this module through an online link via the Canvas system. Pre- and post-module surveys evaluate education effectiveness, while the background information survey assesses student participant demographics. Participation in the intervention is part of the required course curriculum and is implemented online; however, survey results are anonymous and confidential. Therefore, students need to contact their instructor directly via Canvas email if they do not want their anonymous data shared for educational purposes, such as module improvement. Data is used to assess module effectiveness in improving vaccine knowledge among FYE students. Instrument to Measure the Effectiveness of Intervention Evaluation of intervention success is vital to the refreeze phase of change permanence. The DNP project evaluation can be complex and includes technical, financial, operational, and social components (McBride & Tietze, 2019). Pre- and post-Likert scale-style surveys allow for assessment and evaluation of vaccine module success. Students complete these surveys using Qualtrics links within the University's Canvas course platform. The goal is to see a positive change between education pre- and post-surveys. Qualtrics evaluation of survey information IMPROVING VACCINATION RATES 18 helps the DNP Project Team assess if using an e-learning module improves vaccine education in the specific population. The use of educational technology is expected to improve health-related concerns by increasing vaccine education and uptake in university students and reducing infectious disease outbreaks. Project Implementation Intervention Online Vaccine Educational Module Developed by Experts In collaboration with The Summit Group, a vaccine team comprised of the Utah Scientific Vaccine Advisory Committee and Utah Department of Health (UDoH) created the vaccine module to improve accessibility to vaccine education for college students per the Utah Board of Higher Education mandate. The Summit Group was responsible for web development, including module structure and interactive components. The DNP project leader was granted permission to adapt this module for use at Weber State University. Though the vaccine team gave permission to use and adjust the module, it took several months and many meetings with stakeholders to access the module's online coding necessary for adaptation and use at WSU. Communication between team members was difficult to facilitate and required persistent efforts over several months for the DNP leader to gain access. A meeting with UDoH, The Summit Group, and DNP project team members eventually took place, and the vaccine team granted immediate access to HTML source coding. Upon gaining access to the module, the WSU Academic Web Services web designers were given the necessary information for adaptation and adjustment according to WSU student needs. IMPROVING VACCINATION RATES 19 Description of Online Educational Module This DNP project's vaccine education module intervention is interactive, with various multi-media components compiled in a common-sense database design. The design includes multiple sections to the vaccine education module to be completed in the order presented on the website. A navigation header at the top of the site allows students to monitor their progress through the intervention. At the same time, each page has navigation buttons allowing the student to move through the module in the intended format. Student users begin the intervention by viewing a brief introduction video, showing the DNP student leader and the purpose of the vaccine module as an intervention for the DNP project. The DNP leader educates students regarding module use in the video, with specific information explaining the inclusion of multiple surveys for anonymous data collection (see Appendix B). Once students have finished viewing the introductory video, they proceed to the next section of the module and access the demographic information survey via an independent Qualtrics link (see Appendix C). The survey takes approximately 5 minutes to complete, and then students are guided to return to the module to complete the vaccine education pre-survey (see Appendix D). Following completion of the pre-survey, students begin the vaccine education module. The next section of the vaccine module gives information about infectious diseases, including those frequently found on college campuses. Throughout this section, student participants can click on embedded videos showing an overview of infectious diseases, how they can be spread and how to implement preventative measures. Upon completing this section, students learn about vaccines, how they work, and why they are essential for the immune system. Community immunity is discussed, and videos throughout the section give valuable education IMPROVING VACCINATION RATES 20 addressing vaccine myths and facts. In this section, students can access various vaccine schedules and information regarding vaccine recommendations with an interactive pop quiz to assess vaccine knowledge. Students finish with a post-module survey, and participation in the module is complete (see Appendix E). Vaccine Module Implemented in the First-Year Experience Classes Project implementation occurs in FYE classes via the Canvas platform. FYE instructors introduce and implement the module as part of their curriculum's health and wellness section. As previously stated, students are given access to the vaccine education website to view the introductory video, complete the background information and pre-module survey, and then participate in the module itself. Once the module is finished, the website directs students to the Qualtrics link to complete the post-module survey. The surveys used throughout the module assist DNP and WSU leaders in evaluating the intervention's potential success and if changes need to occur to address stakeholder needs. Alignment of Project Interventions With Short-term Outcome and Overall Outcome Short-term outcomes include essential vaccine education of WSU students who may have previously lacked the information necessary to make informed decisions regarding vaccination, with the program continuing each semester in the FYE courses. The long-term outcome of the project intervention is to increase vaccination rates at WSU by implementing an online vaccine module educating FYE students about the importance of immunizations in preventing outbreaks of vaccine-preventable communicable diseases. The overarching goal is to include all faculty, staff, and general student population access in the future. IMPROVING VACCINATION RATES 21 Project Timeline The DNP project timeline allows for much-needed flexibility throughout project selection, planning, and implementation, covering six semesters (see Appendix F). Collaboration between various stakeholders occurred throughout the project process, and communication between the project team was crucial in project progression. Stakeholders with critical roles throughout the timeline include the DNP Project Team; the State of Utah Vaccine Committee, comprised of UDoH and Utah Scientific Vaccine Advisory Committee; the technology director at The Summit Group; and WSU Webmasters. These stakeholders' communication and collaboration often proved difficult, extending portions of the timeline affecting initial project implementation goals (See Appendix G). Project Evaluation Project evaluation was crucial to understanding success concerning project outcomes and determining if intervention impact was as projected. The intervention implementation occurred over the Fall Semester of 2021, with evaluation completed in Spring 2022. Project evaluation included data collection and analysis, data security and maintenance procedures, and intervention strengths and weaknesses assessment. Data Maintenance/Security No personal and identifying data were collected during the project intervention. Student participants were notified via written information on the top of surveys and the introduction video that their responses would be anonymous and confidential. Students accessed survey questions via links embedded in the module website, and all information was transmitted electronically with survey data collected and stored on Qualtrics servers. Data stored on these servers was password protected and only accessed by the project team leaders. IMPROVING VACCINATION RATES 22 Data Collection and Analysis Both quantitative and qualitative data were collected as part of the intervention. The surveys used in the vaccine education module had multiple response methods, including the Likert scale and free text box options. Subsequently, the results were separated into groups and analyzed according to data type. Sample size variability among surveys is due to incomplete data collection from some participants. Quantitative Data Quantitative data were collected using all three instruments, background, pre-module, and post-module, with most quantitative data originating from the background information survey. This survey was used to understand the sociodemographics of the FYE student population participating in the project intervention. These data were grouped, analyzed, and represented as percentages in Table 1. Data showed 86.25% of student participants were between 16 and 20 years of age, from various declared majors. Of these students, 90% were attending college for the first time, and 17.95% were uninsured. Though many vaccination programs provide vaccines at a free or reduced rate for those without insurance, the number of uninsured students may affect overall immunization rates. Table 1 Participant Background Information Baseline Characteristic n % Age 16-20 69 86.25 21-29 6 7.5 30+ 5 6.25 Children Yes 4 5.00 No 76 95 IMPROVING VACCINATION RATES 23 Declared Major Business, Administration & Finance 6 7.5 Communication & Marketing 2 2.5 Computer & Information Systems 3 3.75 Education 6 7.5 Engineering & Technology 3 3.75 General Studies & Pre-Majors 11 13.75 Health Professions 17 21.25 Integrated Studies 1 1.25 People, Politics & Society 8 10 Professional Trades 1 1.25 Science & Math 8 10 Visual & Performing Arts 6 7.5 Writing, Literature & Languages 2 2.5 Undeclared/Unknown 6 7.5 First Time at a University Yes 72 90 No 8 10 Parent Highest Education Level Some high school 9 11.39 High school graduate 14 17.72 Some college 18 22.78 College graduate 22 27.85 Master's degree 14 17.72 Doctorate degree 2 2.53 Unknown 1 1.25 Type of Health Insurance Student plan 2 2.56 Private 44 56.41 Medicaid 18 23.08 Uninsured 14 17.95 Unknown 2 2.56 Pre- and post-module survey data demonstrated positive vaccine knowledge and hesitancy changes. A wide range of responses existed regarding immunizations students reported IMPROVING VACCINATION RATES 24 to have received, with less than 12% of participants stating they had received each immunization as outlined (see Appendix H). In contrast, 86% (extremely and somewhat likely pre-module) of student participants felt they were up to date on their immunizations (see Appendix I). These data show discrepancies in reported results, further supporting the need for increased immunization education. Additionally, there was a 8% (extremely and somewhat likely) increase in students' expectations of other college students to be up to date on their immunizations. When comparing the likelihood of asking other college students to be immunized, there was a 10.64% (extremely and somewhat likely) increase from pre- to post-survey. Similarly, when asked the likelihood of asking family members to be vaccinated, students' confidence increased after the intervention by 4% (extremely and somewhat likely) (see Appendix I). Qualitative Data Qualitative data were analyzed by coding free responses, then dividing data into categories by response concept. As categories were created, specific themes emerged from the data. Categorizing by theme with inductive reasoning allowed the interpretation of student responses to be organized and represented systematically, as seen in Table 4. Notable changes in this table include the 6.94% increase in concern over vaccine safety. This change could be due to the students increased vaccine knowledge after intervention participation, causing them to reflect on vaccine safety they previously had never considered. Table 4 Pre- and Post-Module Quantitative Survey Data Pre-Module Survey Question n % Post-Module Survey Question n % Biggest immunization concerns Biggest immunization concerns Side effects 34 38.63 Side effects 24 27.58 IMPROVING VACCINATION RATES 25 Allergy 3 3.40 Allergy 2 2.29 Pain 2 2.27 Pain 0 0 Fear 4 4.54 Fear 6 6.89 Skepticism 1 1.13 Skepticism 2 2.29 Others not getting immunized 9 10.22 Others not getting immunized 12 13.79 Misinformation 2 2.27 Misinformation 0 0 Safety 3 3.40 Safety 9 10.34 Personal choice 1 1.13 Personal choice 2 2.29 Illness if unimmunized 1 1.13 Illness if unimmunized 0 0 Other 3 3.40 Other 7 8.04 None 25 28.40 None 23 26.43 Do you need more immunization education? Yes 22 22.68 Probably yes 32 32.99 Maybe 24 24.74 No 19 19.59 Other themes emerged from the post-module survey data and were categorized according to the survey question. Of student participants, 11.75% reported they had received their hepatitis B vaccine, which is the highest. A common theme regarding new information learned during the module is that meningitis affects college-age young adults and has a high mortality rate. Students also reported learning further about how vaccines work and how they benefit the body, including the understanding that many vaccine myths change perceptions. Understanding why vaccines are so important included new knowledge about specific vaccine-preventable diseases that can cause congenital disabilities, such as rubella. Another emerging theme includes gaining knowledge about the number of vaccines available, and most vaccines require multiple doses and the need to check vaccine status. When assessing intervention effectiveness, most students stated that they had no further questions. Participants indicated they felt well informed when completing the post-module IMPROVING VACCINATION RATES 26 survey after intervention completion. Finally, as evidenced by qualitative and quantitative data, students still expressed concern regarding vaccine side effects (see Table 4). When asked whether participants had questions about communicable diseases not covered in the education module, the majority stated they had no questions. At the same time, some expressed a desire for more information about COVID-19. It is important to note that the module was initially created before the pandemic and did not cover any information about COVID-19. Finally, a few participants expressed a desire to know if there are other ways to prevent infectious disease transmission besides vaccines. Findings Qualitative and quantitative data suggest the vaccine education module positively impacted student knowledge and hesitancy. Before the vaccine education module, the data indicated that students primarily had vaccine hesitancy due to concerns about side effects, safety, and others not being immunized. The majority of students felt they needed more vaccine education. After participating in the intervention, there was a perspective shift, and most students had no further questions and felt as though they had received substantial information and knowledge about vaccines. Vaccine knowledge increased among participants, meeting the intervention and DNP project goal. Strengths Intervention strengths include the use of electronic means to collect study data. Electronic access allowed FYE students to anonymously participate by completing associated surveys with ease and minimal user error. Using Qualtrics to collect the data allowed for easy analysis within the Qualtrics platform. Using valid and reliable instruments such as the Likert scale made the quantitative data easier to identify, analyze, and understand results and module efficacy. IMPROVING VACCINATION RATES 27 Intervention implementation was part of the FYE classroom curriculum, which meant the intervention was more likely to have increased participation and capture student responses. Students were more likely to complete surveys and the education module if included in their course curriculum, completing an expected part of online classroom participation. In addition, FYE faculty were encouraged to view the information module to improve participation and student buy-in. Weaknesses The primary weakness of the intervention is the small sample size. Not all FYE students participated in the module, and not all who participated completed all three questionnaires causing variation in data numbers. Different instructors within the FYE department implemented this vaccine module in their curriculum. There was inconsistency throughout classrooms regarding which instructors required participation in the intervention while others left participation optional. Using open-ended response boxes mixed with the Likert scale questions means quantitative and qualitative data were gathered. Combined data provided different viewpoints determining outcome success. While quantitative data was easier to assess through statistical means, the qualitative data provided a better understanding of students' perspectives and changes in attitudes and hesitancy; however, qualitative data was more challenging to analyze and may lead to interpretation bias. Finally, the lack of information on COVID-19 left some participants with questions. Due to the current pandemic, all participants could have benefited from up-to-date information regarding the virus, symptoms, vaccines, and other necessary preventative measures. However, further information should be added to the module in the future to address this critical knowledge IMPROVING VACCINATION RATES 28 gap. Quality Improvement Discussion Quality improvement is a strong focus of the DNP project and includes interpreting evidence and noting implications for practice while anticipating future scholarship opportunities. Upon evaluating intervention data and success, it is essential to understand how to translate the evidence into new and existing practices while addressing outcomes. Assessing project sustainability is crucial to future project success. Once evaluation and sustainability are discussed, it is vital to share this information with others who may benefit from the results and use it to improve the project intervention and implement future changes. Translation of Evidence Into Practice Evidence gained through the literature review identifies vaccine hesitancy among college-age adults. This project intervention addresses these hesitancies while improving vaccine education among this population. Outcomes show that knowledge did increase while hesitation in some areas decreased. These outcomes support the continued implementation of the education module as a regular part of student enrollment on campus at WSU. Data analysis identifies areas where the education module can be adapted and updated to fit current student needs. This information is essential to understand as project sustainability is assessed and practice changes and future scholarship opportunities may occur. Implications for Practice and Future Scholarship Project findings support the continued use of the education module at WSU. The module provides the foundation for advanced vaccine education and improvement in overall population health through increased student knowledge. Sustainability discussions and further project development to include COVID-19 vaccine information allow for future practice scholarship and IMPROVING VACCINATION RATES 29 opportunities for other DNP leaders to address outcomes and changes in WSU vaccine practices and policies. Sustainability Sustainability is crucial to the long-term success of the intervention and permanent change in vaccine hesitancy among college-age adults. Sustainability discussion continues with WSU administrators and faculty to transfer module responsibility from me to another source. Possible sustainability options include assigning full ownership by the WSU Vaccine Committee, continuing module use as part of the FYE health and wellness curriculum, or transitioning module care and maintenance to Student Health Center. As part of the sustainability plan, the department responsible for continuing vaccine module use is granted access to survey forms. The department is responsible for regular evaluation of the module through analyzed survey data, improving and updating as needed or required by a partnership with the Academic Web Services Department. The department will be responsible for updating the module as new vaccines become available or are taken off the market. The Academic Web Services Department continues to host the education module website on WSU servers. This partnership allows the webmasters to update the module as needed, per changes stated by the Vaccine Committee or other responsible parties. Dissemination Project intervention findings dissemination includes sharing data with WSU administration via the Executive Summary and an online meeting with the Dean of Students and nursing leadership. The information discussed in this meeting is further shared with the WSU Vaccine Committee and other staff members as appropriate. I am sharing the information with the FYE director and Weber/Morgan Health Department staff. In addition, I may also submit the IMPROVING VACCINATION RATES 30 intervention paper for review to a peer-reviewed journal. Conclusion A particular need for immunization improvement among college-age adults exists to decrease or eliminate vaccine-preventable disease outbreaks on college campuses. College-age adults can benefit from specific communicable disease and vaccine education to improve knowledge and address vaccine hesitancy. Including this information as part of the curriculum in FYE courses is beneficial to student learning and outcomes. Intervention data show that vaccine educational modules can decrease vaccine hesitancy and increase knowledge, including student understanding of communicable diseases, the purpose and creation of vaccines, and recommendations of vaccines as a primary prevention measure. Future practice scholarship prospects include vaccine module improvement by adding information about COVID-19 and associated vaccines. This project shows promising results for increasing vaccine education in college-age young adults and addresses solutions for hesitancy noted in the literature review. IMPROVING VACCINATION RATES 31 References American College Health Association. (2018). 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Taddio, A., McMurty, C., Shah, V., Riddell, R., Chambers, C., Noel, M., MacDonald, N., Rogers, J., Bucci, L., Mousmanis, P., Lang, E., Halperin, S., Bowles, S., Halpert, C., Ipp, M., Asmundson, G., Rieder, M., Robson, K., Uleryk, E. … Bleeker, E. (2015). Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal, 187(13), 975-982. https://doi.org/10.1503/cmaj.150391 s IMPROVING VACCINATION RATES 35 Tan, L. (2014). Adult vaccination: Now is the time to realize an unfulfilled potential. Human Vaccines & Immunotherapeutics, 11(9), 2158-2166. http://dx.doi.org/10.4161/21645515.2014.982998 Utah Department of Health. (2020). Information for the public: Vaccine-preventable diseases still exist. https://immunize.utah.gov/information-for-the-public/ Utah System of Higher Education. (2018). R714, Capital facilities community impact. https://ushe.edu/ushe-policies/r714-capital-facilities-community-impact/ IMPROVING VACCINATION RATES 36 Appendix A DNP Project Budget IMPROVING VACCINATION RATES 37 Appendix B DNP Project Introduction Video https://www.weber.edu/VaccineEducation/Background.html IMPROVING VACCINATION RATES 38 Appendix C Background Information Survey The following is an online survey that takes approximately 5 minutes. The survey questions will be about basic background information. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of this survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact katherine.turley@mail.weber.edu -What college will you be attending? -What is your age? -Do you have any children? Yes No -What is your major? -Is this your first time at a university since graduating from high school? Yes No -Indicate the highest level of education completed by either of your parents: -Which of the following immunizations have you received: Hep B (Hepatitis B) RV (Rotavirus) DTaP (Diphtheria, tetanus, pertussis) Hib (Haemophilus influenzae type b) PCV13 (Pneumococcal) IPV (Polio) Annual Influenza shot MMR (Measles, Mumps, Rubella) Varicella (Chickenpox) Hep A (Hepatitis A) MenACWY (Meningitis) MenB (Meningitis) Tdap (Tetanus, diphtheria, pertussis) HPV (Human papillomavirus) I Don't Know IMPROVING VACCINATION RATES 39 -What type of health insurance do you have? Student Plan Private Medicaid IMPROVING VACCINATION RATES 40 Appendix D Pre-Module Survey The following is an online survey that takes approximately 5 minutes. The survey questions will be about immunizations. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of this survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact katherine.turley@mail.weber.edu Before you begin the vaccine education module, please answer these questions. Of the following questions, on a scale of 0-10 (0 = not at all and 10 = definitely), how likely are you to do each of the following? 1. How likely are you to be up to date on your immunizations? Not at all Definitely 2. How likely are you to expect other college students to be up to date on their immunizations? Not at all Definitely 3. How likely are you to ask other college students to be immunized? Not at all Definitely 4. How likely are you to ask your family members to be immunized? Not at all Definitely 5. What What is your biggest concern about immunizations? IMPROVING VACCINATION RATES 41 Appendix E Post-Module Survey The following is an online survey that takes approximately 5 minutes. The survey questions will be about immunizations and education received in this module. Your responses to the questions will be confidential, and no identifying information will be collected, such as your name or email. The results of this survey will be reported using aggregate data, keeping responses anonymous and confidential. Data will be used for educational purposes to improve the content. If you have any questions, please contact katherine.turley@mail.weber.edu Now that you have finished the module, please answer these questions. Of the following questions, on a scale of 0-10 (0 = not at all and 10 = definitely), how likely are you to do each of the following? 1. How likely are you to be up to date on your immunizations? Not at all Definitely 2. How likely are you to expect other college students to be up to date on their immunizations? Not at all Definitely 3. How likely are you to ask other college students to be immunized? Not at all Definitely 4. How likely are you to ask your family members to be immunized? Not at all Definitely 5. What What is your biggest concern about immunizations? 6. What NEW piece of information did you learn during this education module? IMPROVING VACCINATION RATES 42 7. What questions do you have about immunizations that were NOT covered in this education module? 8. What questions do you have about communicable diseases that were NOT covered in this education module? IMPROVING VACCINATION RATES 43 Appendix F DNP Project Timeline Task Description Start Date Completion Date Initial discussion with vaccine team member for module use. Spoke with Lacey Eden regarding vaccine module implementation at WSU for DNP project. September 15, 2020 December 10, 2021 Gaining access to vaccine education module. Spoke with various members of the vaccine team to get HTML source coding for the vaccine module. September 2020 July 26, 2021 WSU Academic Web Services module creation and adaptation. Worked with webmaster to create/adapt module to WSU student needs. June 28, 2021 October 19, 2021 Introduction video created with FYE staff. Worked with FYE staff to record module introduction video. September 29, 2021 September 29, 2021 Students complete online vaccine education module. Students complete vaccine education module, with accompanying introduction video and surveys. October 19, 2021 December 10, 2021 Survey data is collected and analyzed. The DNP project leader collects and analyzes project data. Spring 2022 Spring 2022 IMPROVING VACCINATION RATES 44 Appendix G DNP Project Gantt Chart IMPROVING VACCINATION RATES 45 Appendix H Participant Background Information Table 2 Participant Background Information Baseline Characteristic n % Immunizations received Hep B (Hepatitis B) 49 11.75 RV (Rotavirus) 16 3.84 Hib (Haemophilus influenzae) 23 5.52 DTap (Diphtheria, tetanus, pertussis) 33 7.91 PCV13 (Pneumococcal) 17 4.08 IPV (Polio) 25 6.00 Annual influenza 40 9.59 MMR (Measles, mumps, rubella) 33 7.91 Varicella (Chicken pox) 35 8.39 Hep A (Hepatitis A) 38 9.11 Tdap (Tetanus, diphtheria, pertussis) 36 8.63 HPV (Human papilloma virus) 32 7.67 MenB (Meningitis) 19 4.56 MenACWY (Meningitis) 17 4.08 Johnson & Johnson (COVID-19) 4 0.96 IMPROVING VACCINATION RATES 46 Appendix I Pre- and Post-Module Survey Table 3 Pre- and Post-Module Survey Question Pre-Module Post-Module n % n % How likely are you to be up to date on your immunizations? 0 3 3.16 2 2.06 1 1 1.05 2 2.06 2 3 3.16 0 0 3 6 6.32 8 8.25 4 39 41.05 30 30.93 5 43 45.26 55 56.70 How likely are you to expect other college students to be up to date on their immunizations? 0 1 1.04 5 5.15 1 5 5.21 2 2.06 2 13 13.54 7 7.22 3 35 36.46 33 34.02 4 27 28.13 27 27.84 5 15 15.63 23 23.71 How likely are you to ask other college students to be immunized? 0 18 21.18 13 14.77 1 29 34.12 12 13.64 2 13 15.29 15 17.05 3 7 8.24 20 22.73 4 9 10.59 12 13.64 5 9 10.59 16 18.18 How likely are you to ask your family members to be immunized? 0 9 10.11 8 8.60 1 7 7.87 5 5.38 2 10 11.24 5 5.38 3 10 11.24 16 17.20 4 28 31.46 24 25.81 5 25 28.09 35 37.63 Note: Original 10-point scale survey reduced to 5-point as shown above with the following scale criteria: 0-1 extremely unlikely, 1-2 somewhat unlikely, 2-3 neither likely or unlikely, 3-4 somewhat likely, and 4-5 extremely likely.