Background
Schools have become an increasingly important setting for delivery of immunisation programmes in high income countries. Beginning in some countries with polio vaccination in the 1950s, generations of children have received vaccinations through school-based programmes. Many countries have recently expanded their childhood immunisation programmes to incorporate new vaccinations such as annual intranasal influenza vaccine for healthy children and Human Papillomavirus (HPV) vaccination for teenage girls [
1]. Schools are an attractive venue for providing these vaccines because of their ability to reach large numbers of children in a short period of time.
Evidence from a wide range of studies shows that school-based vaccination is effective in achieving high uptake and completion rates [
2‐
5]. This evidence comes from different types of school-based programmes: routine and booster immunisation programmes, catch up programmes for unvaccinated and partially vaccinated young people, and vaccination in response to an outbreak of disease. Research also shows that school-based vaccination is successful in reducing the burden of disease in the wider community as well as in the vaccinated population [
4,
6,
7]. Studies have found school-based vaccination to be acceptable to education staff, health professionals, parents and students even when programmes involve new vaccines and parental concerns figure strongly [
8,
9].
There are, however, considerable political, organisational and logistical challenges to delivery of such large scale programmes in schools. Challenges include which organisational and funding models should be selected, questions about vaccine supply and distribution, issues around staff capacity and workload, as well as how to inform parents, obtain consent, and minimise anxiety and distress to students. The exact nature of these challenges and approaches for successfully overcoming them are not currently well understood.
With the advent of further new vaccines on the horizon, it is likely that mass vaccination programmes will be a more frequent event in the school timetable [
10]. Understanding the processes that influence school-based vaccination programmes is important information for shaping strategy and policy for future programmes. Our review aims to identify the factors that influence successful delivery in order to support more effective programme design and implementation. We aimed to identify the contextual and organisational influences, enablers and barriers which impact on the delivery of programmes in school-based settings.
Methods
We undertook a systematic review using a narrative synthesis approach. Narrative synthesis is an established method used in systematic reviews to review and integrate diverse forms of evidence [
11,
12]. Evidence for organisational influences on school-based vaccination can be found in heterogeneous studies, including process evaluations which vary in the degree to which formal research methods are used. This approach suited our research question because it enabled us to look for, include and synthesise evidence from different types of studies.
Our first step was to conduct a scoping review of the literature to enable us to trial search terms for our full review, and to identify emerging themes for coding our results. Our scoping review generated eight broad organisational factors that researchers across different studies and from different countries identified as significant influences on the delivery of school-based programmes. We used these eight factors to develop a thematic framework consisting of inductively-constructed codes which we would later use to group our findings from the studies we included in our full review (Table
1).
Table 1
Coding framework for thematic analysis based on organisational influences on the implementation of school—based programmes
A | National and regional policy | Directly related policy, e.g. the aims/target group for the vaccination programme Indirectly related policy, e.g. education policy, health service policy |
B | Programme management and leadership | Leadership and management of the programme at local, area and national levels |
C | Organisational models and institutional relationships | Models of programme organisation and inter-organisational communication and collaboration |
D | Infrastructure | Facilities and systems for the programme, e.g. systems for vaccine distribution and supply, data systems for vaccination records |
E | Workforce: capacity and activity | Staff capacity, workload, skill, experience and roles |
F | Programme financing | Resourcing, billing and reimbursement, sustainability |
G | Communication with parents and students | Practical issues, e.g. distribution of consent forms and obtaining consent Conceptual issues, e.g. tailoring messages, involving children and adolescents |
H | Clinic organisation and delivery | Logistics on the day, physical configuration of clinics |
For our full review, we conducted searches on two electronic databases: MEDLINE and Health Management Information Consortium (HMIC — a bibliographic database of health management and policy). For our searches we used the National Institute for Health and Care Excellence (NICE) search platform (
https://www.evidence.nhs.uk). We limited our search to studies in English and published between 2000 and 2015. The year 2000 was our cut-off due to limited capacity in our team. Our last search was conducted on 30 August 2015. One of our searches is reproduced in full in an appendix [see Additional file
1]. We searched the Cochrane library by topic and review. In addition, we hand searched public health journals, looked for studies cited in systematic reviews, and contacted one study author to obtain an additional article.
We screened studies by title and abstract, and retrieved full text articles. Studies were included if they met the following criteria: (1) focused on childhood or adolescent vaccination programmes delivered in schools; (2) considered organisational factors that influenced the preparation or delivery of programmes; (3) were conducted in a developed or high-income country; and (4) had been peer reviewed. We restricted our study to high income countries because we were interested in comparing results for countries with similar vaccination schedules and with more developed health and education systems. As long as the above criteria were met, studies of any vaccination programme were included: i.e. covering routine immunisations, catch up programmes for unvaccinated or partially vaccinated children, and vaccinations in response to a disease outbreak. We excluded studies that examined attitudes to and beliefs about vaccination, focused on impact with no analysis of process, or involved the use of schools for immunisation of the local community rather than school students.
We coded the included studies by study type, country and vaccine programme (Tables
2 and
3). For study type, we classified studies into five categories (I to V) based on main methods reported. We appraised the quality of studies in three of our categories (I, II and III), including an assessment of the risk of bias, using checklists that we adapted from the UK’s Critical Appraisal Skills Programme. These checklists are shown in an appendix [see Additional file
2]. We did not assess the quality of descriptive studies and expert opinion pieces (i.e. categories IV and V) as there was insufficient detail within these studies on methods used. We appraised the quality of papers in order to describe that quality and to inform our synthesis of findings rather than to include or exclude [
13]. In our analysis, we gave papers of lower quality less weight than those that were of higher quality.
Table 2
Included studies by study type, coded by main methods used
I Reviews/synthesis of studies | Systematic review, narrative review | 3 |
II Quantitative | Cohort analysis, cross-sectional survey, economic evaluation | 7 |
III Qualitative | Focus groups, semi-structured interviews, observations | 15 |
IV Descriptive | Descriptions of programme experiences, local evaluations | 16 |
V Non-research | Expert opinion/conference paper | 3 |
| TOTAL | 44 |
Table 3
Included studies by country and vaccine disease type
Australia, HPV | 2 | Bernard 2011 [ 17], Robbins 2010 [ 47] |
Australia, various diseases | 2 | Marshall 2014 [ 40], Ward 2010 [ 52] |
Canada, varicella | 1 | |
US, seasonal influenza | 12 | Carpenter 2007 [ 20], Lott 2012 [ 37, 38] |
US, H1N1 | 9 | Ambrose 2011 [ 14], Klaiman 2014 [ 30] |
US, hepatitis A and B | 4 | Mark 2001 [ 39], Tung 2005 [ 51] |
US, various diseases | 2 | Limper 2014 [ 34], Lindley 2008 [ 35] |
UK, HPV | 8 | Hilton 2011 [ 25], Potts 2013 [ 45] |
UK, seasonal influenza | 1 | |
UK, hepatitis B | 1 | |
Worldwide, various diseases | 2 | Cawley 2010 [ 21], Cooper Robbins 2011 [ 23] |
TOTAL | 44 | |
We extracted data from the studies and coded findings using the thematic framework of eight organisational factors that we had developed from our scoping review. We compared and contrasted findings within and across studies. One researcher (SP) performed the systematic searches, data extraction, coding and analysis of findings. A sample of ten percent of included and excluded studies was reviewed by a second researcher (ST) to check consistency in the application of the inclusion and exclusion criteria, the quality appraisal criteria, and the coding template. Discrepancies were discussed and agreed between SP and ST.
Discussion
We found 44 studies of school-based vaccination that yielded information on the organisational factors that influence the implementation of programmes. Using the thematic framework that we had developed from our initial scoping review, we were able to identify a number of common themes from the literature. Factors that featured strongly in studies included programme leadership and governance, organisational models and institutional relationships, workforce capacity and roles particularly concerning the school nurse, communication with parents and students, including methods for obtaining consent, and clinic organisation and delivery. This is the first time that this information has been brought together and is important for understanding how school-based vaccination programmes work.
These themes relate to each other in a number of ways. For example, funding and staff capacity are clearly linked. In the US, where schools lacked a stable funding stream for seasonal flu vaccination, programmes relied on parent and health service volunteers. In the UK, where there is a centralised funding stream for school programmes, nurses still felt under-resourced and burdened by the additional workload created by vaccination programmes. Managing parental concerns and gaining consent was also a recurring theme, linked closely to workforce capacity and activity, and to inter-organisational relationships. Persistent efforts by committed school and health staff, often working in close collaboration, were needed to maximise high rates of consent form return, high uptake and reduce inequalities.
Our interpretation of the literature is that programmes may work best when all eight organisational factors are positively aligned in a way that facilitates school-based programmes. However, with few rigorous evaluative studies and with studies offering a variety of definitions for ‘successful’ programmes, we cannot be sure that this is the case. Effective programmes appear to be ones with sufficient nursing staff, who are experienced and knowledgeable about immunisation, familiar with the communities with which they work, and able to provide parents with clear confident messages about the safety and benefits of vaccination [
18,
27]. Support for nurses to do this appears to come from whole school commitment and involvement starting from school leadership, and backed up by strong professional and institutional relationships between the health and education teams [
26]. National policy may either strengthen or weaken the conditions for this to happen. For example, major reform of the education system in the UK, allowing for the creation of state schools independent of local authority control, made the initial implementation of HPV vaccination difficult.
Drawing conclusions is difficult because of the limitations and gaps in the literature. The studies we identified occupy a relatively narrow field dominated by studies of pandemic and non-pandemic influenza vaccination in the US. This limited our ability to consider how different organisational influences affect implementation of programmes in various settings and policy contexts. We recognise that our search strategy may have artificially narrowed the full spectrum of studies published in this area and we discuss this further below. A further constraint we identified is the lack of theory-driven analyses using robust evaluation methods. The preponderance of descriptive papers is problematic. These studies provide detailed accounts of programme experiences, packed with potentially very rich data. However, the quality of these accounts is variable with a high proportion lacking sufficient information about research methods, and a clear definition of outcomes.
A particular feature of the literature is the absence of theories of implementation and organisational change. Exploring this literature would help researchers understand better the organisation and delivery of school-based programmes. For example, academic work on professions and boundaries sheds light on how professional identities are conceptualised and how this can affect intra and inter-professional communication and implementation of new initiatives [
58]. This is particularly relevant for our review which found that the role of school nurses and their relationship to other individuals involved in school vaccination featured strongly. Understanding how nurses configure their professional identity and role has implications for school nursing engagement and programme planning. Similarly, theories from improvement research and implementation science can help to explain the enablers and barriers for translation of policy into practice [
59,
60]. For school vaccination, these theories can contribute to understanding which factors influence success when national policy on a new immunisation programme is translated into local programmes, and how local planning can seek to maximise the value of these factors. The field of leadership theory, including shared and distributed theories of leadership, is another area which could inform knowledge of effective programmes by helping to explain the influence of different leadership styles on the implementation of school-based vaccination programmes [
61]. In one of our studies strong hierarchical leadership appeared to be effective for an emergency pandemic situation [
27]. Whether this was effective and acceptable for other scenarios (e.g. more routine delivery) is not clear, as we found that encouraging school engagement is important — suggesting a role for distributed leadership perhaps in combination with aspects of hierarchical approaches.
A further gap we identified was the shortage of studies that considered the views of parents, children and teenagers on the organisational aspects of school programmes, an issue also identified by Cooper Robbins’ systematic review [
24]. The few studies that have looked at this issue have found that the way that vaccine clinics are organised can impact on young people’s emotions. Boyce [
18,
24] there are strong ethical as well and practical arguments for considering this issue further. The current generation of young people will receive far more vaccines in their lifetime than previous ones. They or their parents may be more or less likely to respond favourably to the next vaccination offered depending on their experience of the school vaccination process.
Some limitations to our study should be considered. Firstly, our searches were confined to studies from high income countries published in English between the years 2000 and 2015. It is likely that this led us to miss relevant studies from other European countries. Limiting our review to 2000–2015 will also have excluded earlier studies of school-based programmes, for example those involving Hepatitis B and TB immunisation. Secondly, our included studies were heterogeneous including formal and informal research and different measures of success. All included studies had been peer-reviewed but quality varied. This variability of methods and limited comparability of findings constrained our ability to draw conclusions from our findings. However, we were interested in the insights that diverse forms of evidence can provide, and we have tried to make the impact of differences in research methods visible by clearly comparing and contrasting results.
Conclusions
There have been remarkable discoveries in the fields of immunisation and vaccination in recent years, including vaccines for meningitis B, rotavirus, and HPV. Several new vaccines are likely to be added to the childhood immunisation schedule of different countries in the near future [
10]. Policy makers will be increasingly drawn to schools as a setting for delivery of these vaccines because of the high vaccination rates that can be achieved. Our study sheds some light on the key organisational influences which impact on the delivery of school-based vaccination.
We identified several organisational factors that are important for the delivery of school-based vaccination programmes, including programme leadership, institutional and professional relationships, and workforce capacity. An understanding of these factors, underpinned by robust theory-informed research, may help policy-makers and managers design and deliver better school-based programmes. We therefore set out the following agenda for future research. Firstly, there is a need for high quality programme evaluations including qualitative studies of processes. Secondly, an increase in studies which are theory-informed, drawing from the literature on theories of implementation and organisational change, will improve understanding of how school-based vaccination programmes work. We have outlined several directions future research might take, such as multi-level studies that explore the interactions between organisational factors (meso), professional roles and identity (micro), and policy imperatives (macro), and how interplay between these levels influences programme implementation. Finally, future research needs to focus on the experiences of children and young people of school-based delivery.
Acknowledgements
Not applicable.