Healthcare providers need powerful resources to turn exemption conversations into vaccination opportunities. “The Greater Risk? Disease vs. Vaccine” card sets and “Understand the Disease…Recognize the Risk-A Guide for Parents” brochures work in tandem to educate parents and help them make the best possible decisions for themselves, their families, and their communities. Goals for “The Greater Risk? Disease vs. Vaccine” Cards Sets plus Parent Brochure To reduce the number of exemptions from vaccines required for child care/preschool and grades K-12 school attendance in Snohomish County.
Snohomish Health District
"The Greater Risk? Disease vs. Vaccine" Card Set + "Understand the Disease…Recognize the Risk - A Guide for Parents"
Snohomish Health District (SHD) is located in Everett, Washington and serves all of Snohomish County, the 3rd most populated county in the state. The county is bordered by the Cascade Mountains on the east and Puget Sound on the west. Everett is about 30 miles north of Seattle on the Puget Sound coast. Before the widespread use of vaccines, communicable diseases caused untold suffering and death. In the pre-vaccine era, 20% of children did not live to their 5th birthdays. The incidence and mortality of these diseases has been reduced 90-99% through vaccinations. Most of today’s parents have never seen a case of diphtheria or measles. The rarity of these diseases and lack of knowledge about them has resulted in parents who are now more afraid of a vaccine than the disease it prevents. They are “hesitant” to vaccinate their children. They do not perceive the true risk of harm or death to an unimmunized child caused by a vaccine-preventable disease. In 2011, Washington State had the highest vaccine exemption rate in the United States. Six percent of the state’s school-aged children were not fully immunized against vaccine-preventable diseases. Public health officials fear that these rates are too low to confer community immunity and that forgotten diseases and their complications will reappear. In July, 2011, the state legislature enacted a law that requires parents to get information about the risks and benefits of vaccination from a licensed healthcare provider before obtaining an exemption for their child. The exemption form must be signed by that healthcare provider. Previously, in Washington State, parents could simply sign a form to receive the exemption. The new exemption law is an opportunity to educate parents about the dangerous diseases that can threaten communities when vaccination rates are too low. Healthcare providers need powerful resources to turn exemption conversations into vaccination opportunities. “The Greater Risk? Disease vs. Vaccine” card sets and “Understand the Disease…Recognize the Risk-A Guide for Parents” brochures work in tandem to educate parents and help them make the best possible decisions for themselves, their families, and their communities. Goals for “The Greater Risk? Disease vs. Vaccine” Cards Sets plus Parent Brochure To reduce the number of exemptions from vaccines required for child care/preschool and grades K-12 school attendance in Snohomish County. To increase the percentage of children in Snohomish County who are fully vaccinated according to Advisory Committee on Immunization Practices (ACIP) recommendations.Objectives 1. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who seek exemptions from school vaccine requirements. 2. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who are hesitant to vaccinate according to ACIP recommendations. 3. Parents will use “Understand the Disease…Recognize the Risk - A Guide for Parents” to weigh vaccine risks against risks of contracting vaccine-preventable diseases and help them to make informed vaccine decisions. The disease/vaccine cards were developed during the fall of 2011 and distributed to vaccinators during our annual “Quick Visits” to Vaccines for Children (VFC) providers in June 2012. Sets were given to SHD employees and “vaccine champions” of Local Health Jurisdictions all over Washington State. Word of mouth recommendations and advertisements in vaccine-themed newsletters resulted in several orders through the SHD website.
An online survey confirmed that vaccinators found the card set format accessible and the information useful for vaccine counseling and education. However, parents who were hesitant to vaccinate did not usually change their minds during the office visit. Feedback indicated a need for a parent-oriented guide to continue the educational process at home. We will continue to monitor progress in lowering school exemption rates and raising overall vaccination rates as providers use the parent brochure in conjunction with the card sets. The exemption law definitely impacted Washington State’s vaccine exemption rates, especially at the Kindergarten entry level, where there was a 25% reduction during the first year of implementation. However, Snohomish County’s exemption rates are higher than the state average, so a standardized educational effort that begins in the provider’s office and continues in the home is needed to keep the disease risk vs. vaccine risk debate going. Many vaccine-hesitant parents do decide to vaccinate according to their providers’ recommendations when they have enough time to reflect on the possible consequences of their decisions.
Snohomish Health District (SHD) is located in Everett, Washington and serves all of Snohomish County, the 3rd most populated county in the state. The county is bordered by the Cascade Mountains on the east and Puget Sound on the west. Everett, the largest city in the county, is about 30 miles north of Seattle on the Puget Sound coast. Everett is an urban area that houses a U.S. Naval Base and a growing commercial port. The South County area is suburban, bordering on Seattle’s King County. Small, but growing towns dot the northeast quadrant and central area of the county. Population bases are smaller and more spread apart as they approach and nestle into the Cascades. Fishing, lumber, agriculture, manufacturing, aerotech, and outdoor recreation industries support Snohomish County families. Washington State has traditionally allowed parents to exempt their children from the vaccines required for school attendance simply by signing a form to state their opposition to vaccination for philosophical or religious reasons. It is believed that, while many parents do have sincere objections, some exemptions were taken for convenience. Signing the form was easier than taking their children to a healthcare provider. To combat these “convenience” exemptions, a law requiring education about the benefits and risks of vaccination and a signature from the healthcare provider who performed the education was put in place on July 22, 2011. This law brought about a significant decrease in exemptions for the 2011-12 and 2012-13 school years. However, exemption rates in Snohomish County remain above the state average and rates for all recommended vaccines are below levels needed to support community immunity. Public Health officials are especially concerned about “pockets” of unvaccinated and under-vaccinated children susceptible to disease outbreaks in the county and Washington State.
The target population for this intervention is children under 19 years of age who, in Washington State, are eligible to receive vaccines at no cost and their parents and healthcare providers. The Washington Vaccine Association (WVA) ensures that children can obtain all recommended vaccines by combining federal and state funds with insurance revenue. The vaccines are distributed to Vaccines for Children (VFC) providers who have the potential to immunize all 159,787 children, ages 18 and under, in the county. There are currently 88 VFC providers in the county, including 2 Snohomish Health District Immunization Clinics. One hundred percent of Snohomish County’s VFC vaccinators received “The Greater Risk? Disease vs. Vaccine” card sets and can access printable versions of “Understand the Disease…Recognize the Risk-A Guide for Parents” on the SHD website. Pharmaceutical companies have produced pictures of diseases to promote their products. Merck, for example, has a wall chart for the differential diagnosis of rash illnesses in children. Measles, mumps, rubella, and varicella are not as common as they were before the development of the vaccines. The pictures remind parents that these extremely contagious, dangerous diseases can be prevented through vaccination. The Oregon Department of Human Services Immunization Program produced a bilingual booklet describing 13 of the vaccine-preventable diseases. The description includes a picture of the disease, its symptoms, and its complications. Vaccines have been such a success story that the diseases are not commonly seen now and are not considered to be a risk when contracted by otherwise healthy children. Many providers have not seen the vaccine-preventable diseases in years which may delay a diagnosis and treatment and young parents do not know the devastation they can cause. Permanent disabilities and even death are not considered when weighing the decision to vaccinate; the diseases are no longer commonplace in modern medicine. The threat parents are left to consider is “how safe is the vaccine?” The new practice acknowledges the risks associated with the diseases and the vaccines and provides clear information for parents making health decisions for their families. “The Greater Risk? Disease vs. Vaccine” card set describes 16 vaccine-preventable diseases and the vaccines that prevent them. The front of each card has a picture of the disease and lists the agent, transmission channel, incubation period, symptoms, contagiousness, complications, risks, and treatment. The back of the card describes the vaccine’s appearance, dose and route, and the vaccine’s risks and contraindications. There is also a page that catalogs safety considerations for administering vaccines. It covers universal contraindications for vaccines, defines a true contraindication and a precaution, lists common false contraindications, and states considerations for the immune-compromised and patients who recently received antibody-containing products. Providers can find the facts they need to compare disease risks and complications with the vaccine risks, back to back on one card. The disease/vaccine card set format puts vital information right into the vaccinator’s pocket.
The parent brochure is intended to finish the educational process begun in the provider’s office. It is a “plain language” document that clearly states the risks associated with vaccine-preventable diseases and provides a basis for comparison to the risks of the vaccines. It includes some pictures of children affected by vaccine-preventable diseases, disease symptoms and possible complications, and a brief explanation of the two types of vaccines used. The card sets and parent brochures are vivid reminders of the suffering caused by vaccine-preventable diseases. They educate parents about the role vaccines have played in reducing their occurrence. We hope that these resources, rather than actual disease outbreaks, will convince parents to vaccinate their children fully and to catch up with scheduled recommendations if they have previously delayed or refused any vaccines. To determine that “The Greater Risk? Disease vs. Vaccine” card set was a new resource to the field of vaccination/public health, members of Snohomish Health District’s Vaccine- Preventable Disease Community Program examined immunization-themed websites sponsored by public health organizations, hospitals, non-profit agencies, and coalitions. We found a large number of resources to be used for education about vaccines. One example is the “Vaccine and Immunizations” section of the Centers for Disease Control (CDC) website. Following a link will take the reader to the “Talking About Vaccinations” page which lists different topics and publications appropriate for different situations and groups. There are videos, fact sheets, disease sheets, and information about school attendance and exclusion for parents who choose not to vaccinate their children. The Immunization Action Coalition (IAC) subsidizes a website entitled “Vaccine Information for the Public and Health Professionals.” Again, there are numerous resources available. The site offers descriptive pictures and words, a collection of “unprotected people reports,” and photographs and video clips of vaccine preventable diseases. The information vaccinators need is available in many forms. However, no resource or tool had the information arranged in the accessible, connected format of “The Greater Risk? Disease vs. Vaccine” card set. Disease risk cards backed by vaccine risks, along with a reference card listing safety considerations in vaccine administration, is a unique combination in the vast assortment of immunization and vaccine resources. To complete the educational process, the “Understand the Disease…Recognize the Risk – A Guide for Parents” brochure reinforces the providers’ messages and allows parents the time they may need to consider or reconsider vaccinating their children according to school requirements and Advisory Committee on Immunization Practices (ACIP) recommendations. According to a Community Preventive Service Task Force, there is insufficient evidence that provider education alone will reduce school requirement exemption rates and raise the percentages of fully- vaccinated children. “The Greater Risk? Disease vs. Vaccine” card set, along with its companion brochure, “Understand the Disease…Recognize the Risk – A Guide for Parents,” is designed to support and supplement a comprehensive vaccination program that employs evidence-based practices. The same task force finds strong evidence that developing and enforcing policies and laws will raise immunization rates. As of July 22, 2011, Washington State law requires that parents receive information about the benefits and risks of vaccination from a licensed healthcare provider before that provider is able to sign an exemption from school vaccination requirements.
“The Greater Risk? Disease vs. Vaccine” card sets help healthcare providers to fulfill the education requirement in a standardized, accessible way and encourage parents to choose the risk of a vaccine over the risk of a disease. “Understand the Disease…Recognize the Risk – A Guide for Parents” brochures allow the educational process to continue at home as parents learn about the risks of all vaccine-preventable diseases and (re)consider vaccines their healthcare providers recommend. Strong evidence also supports reducing out-of-pocket costs for childhood immunizations as a way to lower school exemption rates and increase the numbers of fully immunized children. In 1990, Washington State funded universal access to all recommended childhood vaccines for its children, followed in 1993 by the federal Vaccines for Children (VFC) program. Economic disparities no longer exclude children from vaccine-induced immunity to dangerous diseases. Other facets of these programs strengthen the message for vaccination with evidence-based principles and practices. All VFC providers receive annual AFIX (Assessment, Feedback, Incentives, eXchange) feedback from the state and local public health staff who grant VFC privileges and oversee vaccine storage and handling. AFIX visits are a strategy to help healthcare providers raise immunization coverage rates and improve vaccine administration practices. VFC providers are strongly encouraged to use the Washington State Immunization Information System (WAIIS) to limit missed vaccination opportunities, advise vaccinators on catch-up schedules, forecast needed vaccines, and schedule reminder/recall messages to their patients maintain an on schedule, up-to-date status. Other evidence-based practices that align with Snohomish County VFC programs include a collaborative effort between Snohomish Health District-based WIC programs and Immunization Clinics that ensure access to vaccines for WIC clients. County VFC providers also participate in immunization clinics and events to promote seasonal flu vaccination and raise awareness about vaccine-preventable disease threats and outbreaks. “The Greater Risk? Disease vs. Vaccine” card sets, along with the companion brochure, “Understand the Disease…Recognize the Risk – A Guide for Parents,” enhance the evidence-based practices used in Snohomish County VFC programs by sending a unified message that supports timely and complete immunization for our children.
Goals for “The Greater Risk? Disease vs. Vaccine” Cards Sets plus Parent Brochure To reduce the number of exemptions from vaccines required for child care/preschool and grades K-12 school attendance in Snohomish County. To increase the percentage of children in Snohomish County who are fully vaccinated according to Advisory Committee on Immunization Practices (ACIP) recommendations.Objectives 1. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who seek exemptions from school vaccine requirements. 2. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who are hesitant to vaccinate according to ACIP recommendations. 3. Parents will use “Understand the Disease…Recognize the Risk - A Guide for Parents” to weigh vaccine risks against risks of contracting vaccine-preventable diseases and help them to make informed vaccine decisions. The implementation strategy that produced the card sets, “The Greater Risk? Disease vs. Vaccine,” required Snohomish Health District’s (SHD) Vaccine-Preventable Disease (VPD) team to thoughtfully and thoroughly process the needs presented by community stakeholders. During the spring and summer of 2011, they determined that a pocket-sized set of cards featuring disease risks on one side and vaccine risks on the other side would be a valuable tool for vaccinators and other stakeholders interested in reaching our goals of raising the county’s immunization rates and lowering school exemption rates. A successful implementation would depend on the resource being functional and adaptable. The size limits would challenge the authors to present important information in a brief and clear manner. The language used needed to convey important medical facts in a way that could be easily understood by parents making decisions about their children’s healthcare. The resource needed to be accessible and portable to take advantage of every opportunity to educate and vaccinate. The important addition of a list of “Safety Considerations in Vaccination” was the final touch in visualizing a finished product. Once the design and format of the “The Greater Risk? Disease vs. Vaccine” card set was determined, the VPD team members gathered pertinent information from available resources. They wrote the disease descriptions, chose suitable pictures, and condensed the vaccine information and instructions to fit the card layout. Proofreading and editing tasks were shared by individuals throughout the health district to ensure medical accuracy, broad readability, and legible formatting. Most of this work took place during the fall of 2011. The disease card sets were completed and ready for distribution to the county’s Vaccines for Children providers and other partners in vaccine education and promotion by late spring of 2012. They were advertised in the VPD quarterly newsletter’s and on the SHD website by early summer and orders began to arrive.
After the back-to-school vaccination season finished, we sent a survey to everyone who received the card sets hoping to hear about parents changing their minds and choosing vaccines over exemption. However, this was not the case. Many of the survey responders did not know if the cards helped to change minds, but felt that the educational process needed to continue outside of the healthcare provider’s office. Feedback from providers indicated a need for a parent-friendly brochure would be an ideal companion to the disease cards for this purpose. We believed that parents were accessing vaccine risk information online, so the parent brochure focused on disease descriptions and risks. The parent brochure was completed and distributed during the summer of 2013 and is available on the SHD website in pdf form to download and print. Together, the disease card sets and the parent brochures address reasons to vaccinate, types of vaccines, vaccine-produced immunity, disease descriptions and statistics on serious complications and mortality associated with vaccine-preventable diseases. Disease card sets were distributed at no cost to all Vaccines for Children (VFC) providers in Snohomish County, Vaccine Coordinators/Program Managers in other Washington Local Health Jurisdictions and various partners in vaccine education and promotion. The planning process and initiation of the production process began in the spring and summer of 2011. The final edit was sent to the printer early in 2012. The cards were laminated, collated, hole-punched, and secured on a 1 inch diameter ring. The resulting card set was an innovative resource to help community stakeholders in Snohomish County to raise immunization rates for its children. Distribution began in spring 2012. The nurses at the Snohomish Health District’s immunization clinics were among the first to receive their copies. “The Greater Risk? Disease vs. Vaccine” card sets were distributed to all 86 enrolled VFC providers during a “quick visit” format. VPD staff visited the Health Care Providers’ offices and spoke to the vaccine coordinator or other available staff member. The SHD representative explained who should receive the resource and how it should be used. Contact information was given in case follow-up was needed. All visits were made in a 3 week time frame during the month of May 2012. Additional card sets were distributed to LHJ representatives from surrounding Washington State counties during an annual forum on June 19, 2012. The card set was introduced to attendees at the July meeting of Washington State’s Immunization Action Coalition. We allowed a 4 month trial period, including the busy back-to-school season, before sending out a survey to collect evaluation data about the uses and effects of the card set. After collecting feedback from the survey, we decided to plan the parent brochure and have it available to vaccinators for the 2013 back-to-school season. Following a trial run at one of the local tribal clinics, the brochure was completed and ready for our 88 (and the number continues to grow….) VFC provider offices to use in June 2013.
Other stakeholders for this project are the Vaccine for Children (VFC) Providers, school nurses, Healthcare Provider Educators, Immunization Action Coalition of Washington members and parents. These stakeholders have a strong interest in raising immunization rates in Snohomish County through accurate vaccine information and safe vaccine handling and administration practices. Our stakeholders and their needs were the inspiration for this project. The medical stakeholders voiced concern over resources that are not helpful in a fast-paced clinical environment. They find other materials to be too lengthy or not convenient to use. The school nurses had print materials for assessing student vaccine records, but not pictures and descriptions of all of the vaccine-preventable diseases. Data collected from focus groups on parent hesitancy found that parents prefer a knowledgeable and empathetic provider who can talk with them about their concerns. A pocket reference like “The Greater Risk? Disease vs. Vaccine” card set can easily help to focus and supplement a conversation about immunization. Educators expressed a desire for a tool that has succinct information about vaccines to enhance course studies that have minimal vaccine curriculum. Implementation began as the stakeholders received card sets to use according to their needs. Four months later, the VPD team sent, via email, a survey to each stakeholder to collect feedback and data for evaluation. The survey was conducted over the phone for the few provider offices without internet access. The data collected helped us to understand the need for and create the companion parent brochure. Snohomish Health District (SHD) has a critical role to assure that the VFC program providers administer viable vaccine to all children less than 19 years of age. The Health District monitors storage and handling, standardizes vaccine administration practices, and provides education and material development to improve the understanding of vaccines. Because SHD is an agency that administers vaccine in its own clinics, our advice comes from experiencing the same issues that providers face in their practices.
Our community collaborations have developed over time. We support VFC Providers directly as they sign new contracts each January to continue their association with the Vaccines for Children program. Snohomish Health District intervenes when vaccine allocations occur due to shortages. We alert providers when it is time to order vaccine, explain protocols for using combination vaccines, implementing complicated vaccine schedules and documenting each vaccine administered. School nurses depend on our support as new vaccines become requirements for school attendance, when there are disease outbreaks, to provide access and training for the state immunization registry and when they need materials to educate and communicate with the school community. Healthcare Provider Educators depend on VPD team members for their expertise and suggestions to augment vaccine curriculums and increase hands-on training opportunities. Snohomish Health District (SHD) runs two immunization clinics that provide services to county residents of all ages. Parents access the SHD website to find documents and information vital to making decisions about immunizing their children. These collaborations and their outcomes are essential elements to our goals of increasing the number of children in Snohomish County who are fully protected from vaccine preventable diseases and lower the number of children who attend school with vaccine exemptions on record. These relationships are important to Snohomish Health District’s vaccination rate goals due to their interactive, collaborative nature. Our community contacts provide information about their needs and challenges in providing and documenting immunizations. The Vaccine-Preventable Disease team works with each individual or group to find solutions that already exist or, if necessary, to create new solutions. Both sides evaluate and update as needed to ensure that each solution is a good fit. Our “The Greater Risk? Disease vs. Vaccine” card sets and companion parent brochures evolved from this type of problem-solving process.
The Vaccine-Preventable Disease Community Program undertook this project as part of its daily mission, working to support the vaccinators in Snohomish County. The work to write, edit, and format the cards was a team effort completed during normal work hours at the Snohomish Health District (SHD) facility. The program budget was able to support the initial $900 cost of printing 150 copies of “The Greater Risk? Disease vs. Vaccine” card sets. The first 150 copies were distributed without cost to our vaccine providers, colleagues, and community stakeholders. When positive response indicated that more copies would be requested, the VPD Program Manager approached the Board of Health for approval of a $10 per copy charge to cover the cost of printing and shipping. The Board agreed to authorize her request. New orders are set at 150 copies each to maximize the bulk ordering discount. Creating the parent brochure was also part of our regular workday. It is available to download and print from the SHD website, which eliminates any transaction costs.
Washington State’s new school vaccine exemption law went into effect on July 22, 2011. The new law required parents who sought exemptions from school vaccine requirements to received education about the risks and benefits of vaccination from a licensed healthcare provider. The only exception is those who “demonstrate membership in a church or religious body that does not believe in medical treatment.” Data from the 2011-12 school year show this law to be a great success. Washington’s school vaccine exemption rate for students entering kindergarten dropped from 6%, the highest in the United States, to 4.5%, a 25% reduction. Rates for that cohort remained fairly stable, at 4.6%, for the 2012-13 school year. The drop in exemption rates means an increase in the uptake of school-required vaccines. Twenty-five percent more of the state’s newest K-12 students are protected from dangerous communicable diseases and complications that could keep them out of school for extended periods of time and endanger vulnerable friends, neighbors and family members. We do not have quantitative data linking the lowered rate to education alone but, unlike previous exemption forms that could simply be signed by a parent, the law gets families into a healthcare provider’s office to have a discussion about vaccines. The risk vs. benefit education about both vaccines and the disease they prevent, along with a recommendation from the provider, is a strong factor in convincing parents to accept the risks of a vaccine over the risk of a vaccine-preventable disease. This applies to all recommended vaccines, not just those required for school attendance. For “hesitant” parents, choosing school-required vaccines is a start that we hope will lead to acceptance of all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Exemption rate drops were also seen in students entering 6th grade. During the 2010-11 school year, 6.3% of Washington State 6th graders had vaccine exemptions on file. After the law took effect in June 2011, the state’s 6th grade exemption rate dropped to 5.5%, a drop of 12.6%. That rate held steady at 5.5% for the 2012-13 school year. Washington State’s overall school exemption rates dropped from 6.3% in 2010-11 to 5.6% in 2011-12 to 5.2 % in 2012-13, a combined drop of 10.3%. These exemption rate drops were very exciting for the people who worked to pass the law, but the efforts to promote vaccines and support the healthcare providers who care for and educate school-aged children and their families continue. Pockets of high exemption rates around the state and county to county differences present a challenge to healthcare providers and public health immunization programs. Snohomish County’s school vaccine exemption rates for the 2012-13 school year are above average in all the cohorts at 5.3% for kindergarteners, 6.3% for 6th graders and 5.9% overall. We do not expect to attain 100% compliance with school requirements and ACIP recommendations, but know that we can maintain and/or improve the rates by supporting the educational efforts of our Snohomish County vaccinators.
“The Greater Risk? Disease vs. Vaccine” card sets are a handy resource for busy vaccinators in healthcare provider offices and clinics all over Snohomish County. Once distributed, they became a go-to guide when needed. An anonymous survey was sent to 75 of the Vaccines For Children providers at the end of back-to-school shot season in 2012. This was the second school year starting under the new Washington State school vaccine exemption law. After one email reminder, 30 responses were received. When asked “How do you use the card set?” 57.1% checked “To counsel parents” and 71.4% checked “To review disease information.” (more than on answer could be checked) When asked “How helpful is this resource to you when communicating with parents?” 64.3% of the respondents answered “Extremely Helpful” or “Very Helpful” with another 21.4% choosing “Moderately Helpful.” The remaining 14.3% found the card set to be “Slightly Helpful” and no one found the set to be “Not Helpful At All.”Some survey respondents used the “Comments” section to include anecdotes and qualitative data. One comment stated that “When children are afraid to get immunized, I show them the cards and explain that these are the diseases the vaccines they are getting prevent.” Another comment says, “We have it in the IZ room and use it if a patient or parent has questions. We like it-a huge help.” A third comment, “Having only 1 copy in the office, the cards didn’t get utilized well. This should greatly improve when there is one per provider and/or exam room so it is always available,” led to the creation of an online ordering process. Objectives 1. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who seek exemptions from school vaccine requirements. 2. Healthcare providers will use “The Greater Risk? Disease vs. Vaccine” card sets to educate parents who are hesitant to vaccinate according to ACIP recommendations. The first two objectives were achieved quickly and easily once the card sets were delivered to vaccinators. We know from our survey results, from conversations with providers and from in-county orders for more card sets that they were used as we had anticipated. Objective 3. Parents will use “Understand the Disease…Recognize the Risk - A Guide for Parents” to weigh vaccine risks against risks of contracting vaccine-preventable diseases and help them to make informed vaccine decisions.
The third objective was added a year after the original introduction of “The Greater Risk? Disease vs. Vaccine” card sets for a couple of reasons. First, only one vaccinator responded positively to a survey question asking whether or not any parents had changed their minds about vaccinating a child because of the card set. Another was that a provider contacted us with a wish for an alternate version of the cards aimed at parents. He suggested simpler language and a format that could be taken home for further examination. We agreed that was a good idea. Parents make vaccine decisions in many different ways and at many different times. Providers report that most parents do choose to vaccinate, but may need time and space to consider the decision. The parent brochure is a connection to the in-office vaccine conversation and leaves the option to vaccinate open. We know that parents access information and misinformation about vaccines on the internet. The parent brochure is intended to educate and inform parents about vaccine-preventable diseases and their complications clearly and accurately using pictures and statistics. They can use the information to weigh the risks of these serious diseases against the risks of the vaccines. We asked the healthcare provider who requested the parent-targeted piece to use the brochure with parents before we released it to the larger community. He felt it was well-suited to the purpose, distributed 50 during the first week and requested more. This objective was to get something into parent hands to reconfirm the messages concerning disease risks vs. vaccine risks. We have since distributed the brochure to other providers, local health jurisdictions and school nurses to use along with “The Greater Risk? Disease vs. Vaccine” card sets. The brochure is now available on the Snohomish Health District website so it can be downloaded and printed as needed. Our third objective has been achieved. DATA was collected via an online survey (Survey Monkey) sent to the 75 provider offices that received a card set. Thirty total responses were received after being sent one time and followed by one reminder email. Responses were collected anonymously. The PERFORMANCE MEASURES for this objective ask the VFC Providers who received the card sets to evaluate each component separately. Results are as follows:QUANTITATIVE DATA 1. Is the purpose of the book clearly stated in the INTRODUCTION? YES 93% NO 0% I DON’T KNOW 7%2. Is the SAFETY CONSIDERATIONS IN VACCINATION page helpful? YES 86% NO 0% I DON’T KNOW 14%
3. Are the DISEASE INFORMATION CARDS clear and informative? YES 100% NO 0% I DON’T KNOW 0% 4. Is the VACCINE INFORMATION useful? YES 86% NO 0% I DON’T KNOW 14% Card set users responded positively, averaging 91.25%, to all 4 PERFORMANCE MEASURES questions. “The Greater Risk? Disease vs. Vaccine” card sets have a format in which pertinent information about disease and vaccine risks can be easily accessed by healthcare providers during the course of an office visit that includes immunization opportunities.
The survey offered respondents an opportunity to include “anything else they would like us to know about the card set.” One comment concerning this performance objective was recorded. “Some of the concern vaccine resistant parents have are not addressed (vaccine vehicle, additives, formaldehyde, etc.)” No modifications were made to “The Greater Risk? Disease vs. Vaccine” card sets after analyzing the survey results. We acknowledge that vaccine ingredients, a valid concern of vaccine-hesitant parents, was not addressed. However, the explanations and evidence needed for those discussions could not fit on the cards due to the unique nature of each vaccine formulation and the number of ingredients each one contains. We can refer clinicians needing such information to existing materials that list vaccine ingredients and the role each one plays in making the vaccine safe, effective, transportable and storable. We did respond to a concern received 8 months after the survey was taken from a vaccinator who felt the need for a more parent-friendly format that could be distributed and taken home. His concern led to the development of “Understand the Disease…Recognize the Risk - A Guide for Parents”. It is free of charge and available to download from the Snohomish Health District website, print and distribute as needed. Unsolicited feedback tells us that the brochure is being used at healthcare provider offices and clinics and by school nurses to educate them about the risks of diseases made rare by the success of vaccines. “The Greater Risk? Disease vs. Vaccine” card sets and “Understand the Disease…Recognize the Risk - A Guide for Parents” work together to answer questions and concerns that parents have about the vaccines that have greatly reduced the pain and suffering caused by diseases that were feared by parents just a generation or two ago.
We learned several valuable lessons while working on this project. First, vaccinators want quick, factual, graphic materials to share with parents. Second, more than one set of cards is needed in an office practice with more than one vaccinator. Third, word of mouth is a powerful marketing tool. This confirmed our belief that these card sets were valuable resources for vaccinators. Next, we acknowledged that this would have been a very different process without access to computers and the internet. Those tools were vital to gathering information and photos, composing, proofreading, editing text, and formatting it all to fit our specifications. We were able to send our data files electronically to the commercial printer who printed, collated, and assembled the card sets. Pooling our knowledge and learning new methods, when necessary, allowed us to streamline the production process. Finally, although we had hoped to provide “The Greater Risk? Disease vs. Vaccine” cards sets free of charge, the demand is more than the health district can support. SHD’s Board of Health approved a $10.00 per copy fee to cover printing and shipping charges. There were additional lessons learned by sharing “The Greater Risk? Disease vs. Vaccine” card sets with partners in private and community healthcare, public health and education. First, was that we, through collaborations with other interested stakeholders, could identify and create a resource needed to raise vaccination rates in Snohomish County. Second, we learned that a group of vaccinators, public health representatives and vaccine advocates, connected through the Immunization Action Coalition of Washington, facilitated both distribution and marketing. Third, we learned that vaccinators could use a parent-focused piece to continue the education started in the provider’s office. In response to that feedback, we created a parent brochure to use in conjunction with the “The Greater Risk? Disease vs. Vaccine” cards sets. Additionally, we filled an order from a local community college bookstore that purchased copies of the card sets for their nursing program students to use as a learning tool in the present and a resource in the future. “The Greater Risk? Disease vs. Vaccine” card sets and “Understand the Disease…Recognize the Risk - A Guide for Parents” are a coordinated, comprehensive resource for vaccine education. They are easily accessible when parents have questions about vaccination during a healthcare provider visit. They focus on the risks of vaccines versus the risks of vaccine-preventable diseases. They provide clear, understandable data so that parents can weigh the risks and make the best choices to protect their families. We believe that the combined vaccine information, back-to-back with disease information, is a better format than multiple resources needing to be accessed. The parent brochure has basic vaccine information, but focuses on diseases that have been forgotten due to the success of vaccines. Parents who don’t recognize the threat of the diseases are unwilling to take any risks that vaccines may present. We hope that the combined card sets and parent guides tackle reasons for hesitancy and persuade parents to accept the risks of recommended vaccines over the risks of contracting a dangerous, vaccine-preventable disease.
We did not perform a cost/benefit analysis on these resources, but can draw from many sources the fact that vaccines prevent serious, dangerous diseases and the complications that inevitably follow, saving lives and millions of dollars in medical costs. Sustainability of “The Greater Risk? Disease vs. Vaccine” card sets and “Understand the Disease…Recognize the Risk - A Guide for Parents” has two components. First is the cost to print and ship copies of the card sets. We have provided a single copy to each of our VFC providers and copies to other stakeholders who are in a position to promote them. Additional card sets can be ordered for $10 each, which covers the cost of printing and shipping. The parent brochures are available on the Snohomish Health District website and can be downloaded and printed without cost. Second is the necessity to update information due to changes in vaccines and/or school requirements or Advisory Committee on Immunization Practices (ACIP) recommendations. Electronic versions of both resources are housed within the Vaccine-Preventable Disease (VPD) Community Program’s server. They can be updated and, in the case of the card sets, printed. Any updates to the parent guide will appear in the online version as soon as they are saved to the pdf. The VPD Community Program team at Snohomish Health District will regularly review these documents to determine the need for and implement any needed changes. Another aspect to sustainability is to find other ways to disseminate the information in the community and champion the cause of accepting the risk of the vaccine over the risk of vaccine-preventable diseases. One instance of that is a local community college using “The Greater Risk? Disease vs. Vaccine” card sets to enrich the vaccine curriculum for nursing program students and equip them with copies for future use.
Another educational use that was inspired by the card sets is “The Wheel of Misfortune” game, which is used at some of the Health Fairs we attend. It was first created for a local community college Health Fair attended by students in healthcare-related majors. The VPD team made two large banners that display enlarged versions of the disease sides of the cards. Then, we created twelve questions about the vaccine-preventable diseases. To play our game, a participant spins the wheel and answers the disease question that corresponds to a “system,” such as liver, lungs, etc. The answers can all be found on the disease card banners. We give a small prize with our logo to anyone who tries the game. This game is a way to engage Health Fair attendees and opens the door for discussion or questions. We also provide plenty of materials, such as pamphlets and brochures, for the Fair goers to take home and make our contact information available for any questions or concerns they may have later.
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