Evaluation of H1N1 Vaccination Clinics Highlights Leadership Role of School Nurses

As part of Maine's efforts to evaluate H1N1 response, the University of Southern Maine (USM) Muskie School of Public Service and the Centers for Disease Control and Prevention (CDC) collaborated to conduct a evaluation of school-based vaccination clinics in Maine. USM focused on qualitative evaluation. The Maine Center for Disease Control and Prevention (Maine CDC), the state public health agency, chose school-based vaccination as its primary mode for distributing H1N1 vaccine. School nurses and other school clinic staff found their roles and responsibilities expanded during fall 2009, and USM's evaluation focused on identifying their perceptions and school and community attributes related to successful school vaccination clinics.

Evaluators used two different methods to obtain information: (1) focus groups with school nurses and (2) on-site interviews with school clinic staff. USM's purpose in conducting the evaluation was to understand practices that contributed to effective school clinics and identify potential problems that public health agencies could address. Although USM is still in the process of analyzing results from the evaluation, preliminary findings are available below.

Focus Groups with School Nurses:

As a first step in the evaluation process, USM staff held six focus groups with school nurses. Focus group topics were intended to identify nurses' specific roles in planning clinics and answer logistic questions about successes and challenges experienced during the mass vaccination process. School nurses expressed satisfaction in their newfound ability to lead such a substantial project and noted that their roles in school policy expanded following their involvement.

Evaluators found that teams and recruitment of volunteers were crucial to running an effective vaccination clinic. Volunteers especially were essential to the success and efficiency of school clinics. School clinic staff identified a large volunteer staff affiliated with elementary and middle schools, including Parent-Teacher Organizations (PTOs), nurses, and nutrition and custodial personnel. Clinic leadership, particularly school nurses, were in a key position to develop the skills and abilities of internal and external volunteer partners. Staff also spent time forging new relationships with vaccine coordinators and hospitals that allowed their clinics to operate on a large scale.

Nurses noted a variety of challenges, especially related to logistic concerns that added to their already busy workload. Logistic burdens included:

    • A large amount of paperwork (i.e., consent forms);


    • The need to address questions and concerns from community members;


    • Occasional lack of support from school administrators; and


    • Vaccine timeline problems, including confusion around when vaccine would be available and cold chain requirements.

School nurses responded to a large number of phone calls and e-mails from parents and healthcare providers about the safety and benefits of the H1N1 vaccine. Nurses felt that the significant amount of time they spent answering questions could have been avoided with targeted public education. They made numerous recommendations to address these issues, including:

    • Ensuring that public communications do not list dates for vaccination clinics before vaccine availability is guaranteed;


    • Improving communication techniques and educational materials that are distributed to the public; and


    • Advocating for funding to cover extra staff and incidentals (e.g., postage).

Site Visits with School Vaccination Clinic Staff:

The second step in the qualitative evaluation process involved site visits to twelve schools that had built their vaccination clinics on different models. Evaluators opened their interview process not only to school nurses, but also to other staff involved with establishing and running school vaccination clinics. Schools selected staff members to be interviewed. USM evaluators asked 17 questions drawn from the information provided in the focus groups with school nurses. Interviewees also filled out a checklist, which identified clinic timelines, along with values and beliefs that may have contributed to schools' decisions to operate on-site vaccination clinics.

Interview results demonstrated the wide variety in schools' techniques and decisions related to H1N1 vaccination. Most schools relied on outside partners to order, deliver, and properly store vaccine. Several schools required that parents be present during the vaccination of elementary-school children, although clinic staff also noticed that children were more cooperative and comfortable when parents were not present. Characteristics considered important to an effective school vaccination clinic included:

    • Significant involvement of school nurses in all aspects of the process;


    • A large group of volunteers from different sectors and clinic leaders' ability to recognize and develop volunteers' skills;


    • Superintendent commitment and support;


    • Ongoing outreach to partnering agencies;


    • A written plan that described workflow; and


    • One go-to person for coordination and leadership.

Preliminary Overall Evaluation Results:

Maine was one of only four states in the nation to achieve a vaccination rate above 60 percent in children ages 6 months to 17 years, and part of this achievement was due to the state's strong focus on school-based mass vaccination clinics. Nurses and other school clinic staff also judged their clinics as successful, noting that many children would not have had the opportunity to receive vaccine outside of schools.

As a result of Maine CDC choosing school clinics as its main approach for distributing H1N1 vaccine, schools assumed a great deal of responsibility for this public health effort. "Belief in the clinics as part of the school's duty was a simple but powerful necessity," said Teresa Hubley, PhD, MPA, Research Associate at the University of Southern Maine. Schools devoted their resources and staff to helping out with a public health emergency, but the way in which school partners came together to help vaccine children had far-reaching implications for public health practice. Promoting influenza vaccination clinics as a particular asset to school systems may make it easier to deliver vaccine to some of society's most at-risk members in the future. "Belief is one part of sustainability, right along with funds for extra expenses and additional temporary staff and a reliable vaccine supply," Hubley said.

School nurses and other clinic personnel found their leadership roles expanded during the course of vaccine delivery and were able to offer substantial comments on the needs and benefits of the overall process. Evaluators took as their main takeaways lessons learned about maintaining a reliable supply of vaccine, streamlining reporting and reimbursement requirements, the necessity of a volunteer staff, the importance of partnerships within schools and with external agencies, and the need for high-level administrative support from superintendents and school district staff. As a result, USM's qualitative evaluation process yielded new information and perspectives on how influenza vaccine can be provided to large numbers of students in school-based settings.

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