Impact of Immunization Education Presentations on the Knowledge and Attitudes of Childcare Providers Julie C. Bartell, BA Mary S. Hayney, PharmD, BCPS University of Wisconsin School of Pharmacy

University of Wisconsin School of Pharmacy Operation Immunization Goals: To educate the public about the benefits and safety of immunizations To provide accessible information about immunizations to all patients To educate the public about the profession of pharmacy To assist pharmacists in developing immunization awareness and delivery programs This study stemmed from a parent education project that was part of Operation Immunization at the University of Wisconsin School of Pharmacy.  Operation Immunization is a program sponsored by the American Pharmacists Association.  Its goal is to educate the public about the benefits and safety of immunizations and about the diseases they can prevent, and provide accessible information about immunizations to all patients including those at high risk and people with limited English skills.  We also educate the public about the profession of pharmacy, including the roles that the pharmacist and the pharmacy student play in patient health and assist pharmacists in developing immunization awareness and delivery programs.  I have been the Operation Immunization coordinator for our program for the past 2 years.

University of Wisconsin School of Pharmacy Operation Immunization Activities: Meningococcal letter writing campaign HIV awareness campaign Travel vaccine brochures Extensive media campaign Daycare education program Some of the activities that we did this past year are listed on this slide.  We organized a meningiococcal letter writing campaign to high school seniors, an HIV awareness campaign, and developed and distributed travel vaccine brouchures with information on recommeended vaccines for popular vacation destinations.  We organized an extensive media campaign working with radio and televison stations, newspapers, and had booths at health fairs and events.  We also organized a daycare education program, from which this research study idea developed.  Schools and colleges of pharmacy across the country develop their own Operation Immunization campaigns and participate in this annual effort.  Last year APhA awarded our program the National Award for our Operation Immunization efforts. 

Objective To measure the knowledge of childcare providers and the value of education to increase immunization knowledge This project stemmed from a parent education project that was part of Operation Immunization at the University of Wisconsin School of Pharmacy. Operation Immunization is a program sponsored by the American Pharmacists Association. Its goal is to educate about and promote immunizations to the public. School and colleges of pharmacy across the country participate in this annual effort. The objective of our study was to measure the knowledge and attitudes of childcare providers and the value of our educational seminar to increase the immunization knowledge of childcare providers.

1995 The childhood immunization schedule grows continually more complex with at least 17 scheduled immunizations prior to age 24 months. In the interest of public health, immunization laws require childcare centers to maintain immunization records and enforce immunization laws for children who attend the center. to 2005

New Recommendations New in 2003-04 New in 2004-05 Influenza immunization of out of home caregivers to young children may decrease the risk of influenza New in 2004-05 Influenza immunization for children aged 6-23 months Influenza has been identified as an important vaccine preventable disease among young children. The American Academy of Pediatrics and the Advisory Committee on Immunization Practices recommend that all children aged 6-23 months be immunized against influenza just last season. Prior to the 2003-04 influenza season which was when we initiated our study, a recommendation for annual influenza for out-of-home caregivers for young children was made. In addition to offering education regarding childhood immunization in general, we also included information regarding this recommendation for childcare providers.

Methods Staff from five local daycare centers participated Educational program delivered by the investigators The study protocol was reviewed by the institutional review board and granted exempt status. Five area daycare centers participated in our survey and educational program during November and December 2003. The educational program was conducted on site at each center as part of the center’s regular staff or educational meetings. The centers’ directors were informed of the pre- and post-test and issued letters of support to the investigators prior to the sessions. The research plan was reviewed by the institutional review board and was granted exempt status. The research aspects of the program were introduced to the center staff emphasizing that participation was voluntary and responses were anonymous. Pre-tests were distributed and documents were collected immediately prior to the educational program. Demographic data was collected at pretest. The program included information about vaccine-preventable diseases particularly those for which immunization for childcare center attendance is required by state law. Further, we emphasized the anticipated recommendation for influenza immunization of all young children aged 6 to 23 months and the current recommendation for annual immunization of their close contacts. Post-tests were administered at the completion of the program.

Data Collection Pre- and post-test administered Demographic data Attitudes toward immunization Knowledge of vaccines and diseases Pre-tests were distributed and documents were collected immediately prior to the educational program. Demographic data was collected at pretest. The program included information about vaccine-preventable diseases particularly those for which immunization for childcare center attendance is required by state law. Further, we emphasized the anticipated recommendation for influenza immunization of all young children aged 6 to 23 months and the current recommendation for annual immunization of their close contacts. Post-tests were administered at the completion of the program.

Demographics 47 pretest and 42 post-test Median age group: 30-39 years old Forty-seven participants completed a pre-test, and 42 post-tests were submitted. We didn’t collect the specific ages of our participants, but rather asked them to indicate in which age range they fell. The median age range of the participants was 30-39 years.

Attitude Toward Immunization Response p value Pretest 3.28 +0.11 >0.4 Post-test 3.11 +0.14 Two statements designed to assess attitude toward immunization were presented on each test, and respondents were asked to indicate their degree of agreement with these. The responses of strongly disagree, disagree, agree, and strongly agree were converted to scores of 1 to 4 for analyses. Statements on the pre-test and the post-test were designed to measure overall attitude toward the importance of immunization. Responses to these statements were compared, and no statistically significant change was noted (pretest mean 3.28 + 0.11 vs. post-test mean 3.11 + 0.14; p>0.4; t test). The study participants at baseline already recognized the importance and were accepting of immunization practices as indicated by the mean scores in the agree to strongly agree range. Click for second part of the table. A post-test question asked the participants to rate the educational value of the presentation. The mean score was 3.4 +0.09 indicating that participants agreed to strongly agreed that the presentation increased their immunization awareness and knowledge. Value 3.40 +0.09 not applicable

Immunization Knowledge Six vaccine knowledge questions Number correct improved from pretest to post-test Score (mean +SE) p value Pretest 4.4 +2.24 <0.04 Post-test 5.0 +0.16 Knowledge about vaccines and the diseases they prevent increased following the presentation. Six questions were included on each test. Click for table. The mean score improved from 4.4 + 0.24 to 5.0 + 0.16 (p<0.04; t test).

Immunization Knowledge Question Pretest (n=47) Post-Test (n=42) p value Adverse effects 33 (70%) 41 (98%) <0.001 Indication 27 (57%) 28 (65%) <0.02 Diseases 32 (68%) 39 (93%) <0.005 Records 36 (77%) 33 (80%) Not significant This table shows the improvement in knowledge for each of the individual questions asked on the tests. We asked questions about expected adverse effects following influenza vaccine, indications for influenza vaccine, clinical presentation of vaccine-preventable diseases, and recordkeeping requirements for childcare centers. The question regarding immunization recordkeeping requirements of the state was the only question for which no increase in knowledge was achieved. Note that the requirements were already well-known among the participants and little incremental change was made.

Indication for Influenza Immunization Immunized in previous season Not Immunized p value Present 2 8 Not Not present 12 25 significant An indication for annual influenza immunization and receipt of influenza vaccine last year was collected on the pretest. An indication for influenza immunization was determined by using a list of diagnoses asking participants if they had ever been told by a physician that they had any of these conditions. Conditions considered were asthma, diabetes, heart problems, lung disease, kidney disease, or a disease that affects the immune system. Of the 10 individuals who reported a health condition for which annual influenza immunization is recommended, two were immunized in the previous season. Those individuals with conditions representing influenza immunization indications were not more likely to be immunized than those without such a medical condition (2/10 vs. 12/37; p>0.7; chi square). An association between age and influenza immunization history was found. Older individuals were more likely to report having received influenza immunization in the prior season.

Age and Influenza Immunization p<0.03; chi square The height of the bars represents the total number of participants in each age group. The blue portion of each bar indicates the number of individuals who reported receiving an influenza vaccine in the prior season. A statistically significant association between age and immunization status was found.

Age and Immunization Rate Immunized in previous season Not Immunized p value < age 50 9 31 <0.02 > age 50 5 2 Those over 50 years of age more likely to be immunized during the previous season than the staff under 50 years old. (5/7 vs. 9/40; p<0.02; Fisher’s exact test).

Knowledge and attitude are important, but action increases immunization rates!

Influenza Immunization Coverage Change p=0.006 Each participant was asked if he/she received an influenza vaccine in the prior season (2002) on the pre-test. On the post-test, each individual was asked if he/she had received or planned to receive the current season’s vaccine (2003). Influenza immunization rates among the childcare staff increased from 30% last year to 60% for the current season based on stated intentions. This large increase is both clinically and statistically significant. Last season Current season

Implications Influenza immunization rates may increase among childcare providers Decreased infection transmission to high risk young children Decreased absenteeism for staff State immunization requirements for attendance http://www.immunize.org/laws/izlaws01-02.pdf Increased influenza immunization rates among childcare workers may decrease infection transmission to young children. As you know, children under 2 years of age are at high risk of hospitalization with influenza infections. Infants under 6 months of age cannot yet receive the influenza vaccine so immunizing their contacts may be a useful means of protecting them. In addition, annual influenza immunization of healthy working adults has been shown to decrease absenteeism and healthcare costs. All states have immunization requirements for children to attend daycare. The enforcement of these requirements is placed on the staff of childcare facilities. A correlation between the ease with which immunization exemption can be taken and decrease in immunization rates has been identified. If a childcare provider does not appreciate the value of immunization, he/she could recommend that a parent exercise the waiver option rather than have a child immunized. For this reason, as well as the need to implement the recommendation for annual influenza immunization of all out-of-home caregivers for very young children, childcare providers must receive education in this important aspect of preventive care of children and adults.

Limitations Long term effects not measured Immunization rates not directly measured The limitations of our study are twofold. We did not design the study to measure knowledge retention or the long-term effect of the immunization education program. This study represents an initial attempt to determine need and effect. We also measured only short-term change in attitude. We did not directly measure change in behavior. For example, did the individuals who said that they planned to receive an influenza vaccine actually do so? Future studies could monitor immunization rates and waivers at daycare centers.

Conclusions Educational program increased providers’ knowledge Strategy for implementation of childcare provider influenza immunization recommendation The results of our study show a need for and the positive effect of immunization education for childcare providers. An immunization educational presentation for childcare providers may increase influenza immunization rates as well as increase knowledge about vaccines and the diseases that they prevent. Given their contact with high risk individuals—children younger than two years of age, educational efforts directed toward out-of-home caregivers may be very useful for the successful implementation of the recommendation that out-of-home caregivers for very young children receive an annual influenza immunization. Programs such as this immunization education session may have a positive effect on knowledge, attitudes and behavior of childcare providers. This approach represents a valuable strategy for implementation of the recommendation that all out-of-home caregivers for children under age 23 months receive an annual influenza vaccine.

Varicella Contagious viral illness Rash, fever Complications include bacterial infection, pneumonia, inflammation of the brain Documentation of immunity (vaccination or infection) needed for daycare and school entry