Normalizing inconvenience to promote childhood vaccination: a qualitative implementation evaluation of a novel Michigan program

Denise F Lillvis,Katia Noyes,Charley Willison

doi:10.1186/s12913-020-05550-6

Denise F Lillvis, Katia Noyes + Show 1 more

Open Access

https://doi.org/10.1186/s12913-020-05550-6

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Abstract

BackgroundIn 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability.MethodsWe conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring).ResultsThere was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring).ConclusionsThe immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Highlights

In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations
Sense-making Across the LHDs interviewed, there was a lack of consensus about who the stakeholders of this new rule and Component or Item
Probe: Is it in-person? Is it one-on-one or in a group? Are they held during the day, in the evenings, or on weekends? Did you see any individuals that lived outside your county at your sessions? What materials are provided? How long do the sessions take on average?

Summary

Introduction

In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. States have taken different policy approaches to address rising exemption rates, such as California’s elimination of nonmedical exemptions and Washington’s requirement that parents have a conversation with a health care provider prior to forgoing mandatory child vaccinations [5, 6]. In 2015, Michigan implemented a new rule requiring parents to attend an in-person education session at a local health department (LHD) prior to receiving a formal waiver from vaccination. Prior to this rule, a parent would only have to sign a form at the school in order to decline mandatory immunizations. The purpose of this study is to assess program implementation from the LHD perspective, identify potential barriers to sustainability and long-term-effectiveness, and propose strategies for improvement

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