Elsevier

Public Health

Volume 129, Issue 12, December 2015, Pages 1627-1629
Public Health

Short Communication
Promoting vaccination: implementation of targeted interventions to enhance access to vaccination services in Quebec (Canada)

https://doi.org/10.1016/j.puhe.2015.07.013Get rights and content

Highlights

  • Over the implementation period, prioritized interventions were implemented or strengthened in many vaccination clinics.

  • However, status quo and abandon of recognized effective practices to increase vaccine uptake were also observed.

  • The implementation of new practices in vaccination services takes time and requires the collaboration of all partners.

Introduction

Health care in Quebec (Canada) is delivered through a publicly funded health care system, which is mostly free at the point of use and has most services provided by private entities. Vaccines are also provided at no charge. More than 75% of children aged 0–4 years are vaccinated by public health nurses in one of the 146 community health services clinics (the remaining proportion are vaccinated in private medical clinics).1 Older children are vaccinated through school-based programs that are administered by the public community health services clinics. Vaccination in Quebec is not mandatory and, in 2014, 71% of children aged two years were fully immunized1 while, in 2013, 78% of girls in Grade 4 received the two recommended doses of the HPV vaccine.2 Although these vaccine uptake rates are high, the objective to vaccinate 95% of children is still not reached. Studies in Quebec have highlighted that despite publicly funded vaccination programs, access to vaccination services was sometimes problematic and important delays were observed in obtaining appointments for childhood vaccination.3, 4, 5

In this context, the Vaccination Promotion Plan (VPP) was published in 2009 with the goal to ensure that all Quebecers have access to the recommended vaccines and are vaccinated according to the schedule, to protect them from vaccine-preventable diseases.6 The development and evaluation of the VPP are under the responsibility of Quebec National Institute of Public Health (INSPQ) and are supported through funding from Quebec Ministry of Health. The committee responsible of the development of the VPP comprises 18 members that are physicians, nurses, public health specialists or social scientists, working at the provincial, regional or local levels. The committee also includes representatives of Quebec Ministry of Health, of Quebec Ministry of Families, Seniors and Status of Women and of Quebec nurses professional order. All levels of the public healthcare system have committed to support the implementation of the VPP recommendations.6

Effective strategies to enhance vaccine coverage were listed in the VPP based on the recommendations of the Task Force on Community Preventive Services.7 The scientific committee responsible of the VPP undertook a prioritization process which ended-up with a list of 12 priority strategies based on the rationale that access to vaccination services should be strengthened before working on increasing community demand for vaccination. A consultation with public health professionals at the regional level and with managers and front-line vaccine providers at the local level (community clinics) to look at the acceptability and feasibility of the strategies resulted in the prioritization of five specific interventions for which an Action Plan was elaborated and published in 2011.8 These interventions include reminder for the two-month vaccination appointment, recall of unvaccinated children at two-month, expanded vaccination services hours and reminder and recall for parents of Grade 4 students. All of these interventions have been shown to be effective to increase vaccine uptake for different vaccines and populations and in different contexts.9

Between April and June 2011, the Action Plan has been diffused in the community clinics by public health professionals in charge of immunization programs at the regional level and all community clinics were required to implement the prioritized interventions as the Action Plan has been endorsed by policy decision-makers at the provincial level. However, no additional human or material resources were given to community clinics to support the implementation of these interventions. To evaluate the implementation of these interventions, online surveys were sent to front-line vaccine providers or local managers in each of the 146 community clinics before the diffusion of the Action Plan (PRE) and after a two-year period dedicated to the implementation of the interventions (POST). Both questionnaires were identical and were designed to elicit information about the level of implementation for each of the prioritized interventions using a 4-point scale (‘always’ ‘often’, ‘sometimes’, ‘never’). Clinics having answered ‘never’ or ‘sometimes’ were considered not having implemented the intervention and were asked why in open-ended questions. The study was exempted from Research Ethics Board approval because it was done as part of the evaluation of a public health intervention.

Section snippets

Implementation of the interventions: results of the PRE and POST surveys

Two regions developed their own Action Plan and were excluded from the PRE/POST surveys. Response rates for the 16 other regions were 95% for the PRE survey (n = 138 community clinics) and 88% for the POST survey (n = 119 community clinics).

Lessons learned

Generally, Quebec parents of incompletely vaccinated children fall into two categories: parents with more negative attitudes toward vaccination who purposively delay or refuse vaccines because their vaccines concerns were not addressed and parents who have difficulties accessing vaccination services (because they don't know when, how and where to have their child vaccinated or because of difficulties in obtaining an appointment).1, 4, 10, 11 The three interventions prioritized to enhance

Acknowledgements

The authors would like to thank all participants in the two surveys. They also would like to acknowledge the contribution of public health professionals in Regional Public Health Directions, as well as the members of the Table de concertation nationale en maladies infectieuses, in the diffusion and implementation of the Action Plan. Finally, the authors would like to thank Ms. Josiane Rivard for her support during the data collection.

Ethical approval

Not required because the study was done as part of the

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