| Objective:The school-located influenza vaccinations(SLIV)can increase influenza vaccination and reduce influenza morbidity among school-aged children.Beijing government has implemented free SLIV program since 2009.However,the vaccination rate has remained low and varied widely among schools.This study aimed to systematically identify barriers and facilitators of SLIV program implementation among school-aged children in Beijing,so as to provide implications to enhance the implementation of policy and prevent influenza in school-aged children.Methods:Guided by the Consolidated Framework for Implementation Research(CFIR),a Mixed Methods Research was conducted to identify system-based barriers and facilitators from the perspectives of providers and recipients of SLIV program.Under"Inner Setting","Outer Setting" and "Individuals" domains of CFIR,qualitative and quantitative data were integrated using Convergent Mixed Methods Design.Samples for qualitative and quantitative data were independent from each other,and the data were analyzed independently.Qualitative in-depth semi-structured interviews were conducted from September to December 2021 with diverse key stakeholders involved in SLIV program in Beijing,including representatives of Department of Health,Department of Education,schools,and parents.Respondents were identified by purposive and snowball sampling,data collection ceased after reaching thematic saturation.Themes and subthemes regarding barriers and facilitators were generated using deductive and inductive approaches.Quantitative methods were used to further supplement and validate qualitative results.In terms of providers,all 29 school physicians,the key implementers of SLIV program,from 20 primary schools(or campuses,if a school was consisted by multiple campuses)in a district of Beijing were selected by purposive sampling.Structured questionnaire surveys were conducted in September 2022 to analyze the factors of school physicians.In terms of recipients,based on the Health Belief Model nested in the "Individuals" domain of CFIR,a structured questionnaire was designed.The parents,main decision makers for influenza vaccination of school-age children,were surveyed from November to December 2022.A total of 1 584 parents of second-and third-grade children from 10 primary schools in a district of Beijing were selected by purposive sampling.The associations between influenza vaccination among school-aged children and parental intention to vaccinate children next year and health beliefs were analyzed using multiple logistic regression and Structural Equation Model.Results:We included 24 respondents in qualitative interviewed,27 school physicians from 18 schools and 1 277 parents from 10 schools with valid data in quantitative survey.Among which,after excluding two schools which did not deliver SLIV due to COVID-19 pandemic,1 013 fathers/mothers from the other 8 schools were included for exploring recipient-level factors regarding school-aged children’s vaccination.By integrating qualitative and quantitative data,the main barriers to SLIV program involved:the "Critical incidents"(e.g.,SLIV conflicted with school-located COVID-19 vaccination)and "Local conditions"(e.g.,difficulty in coordinating the schedule of on-campus vaccination)constructs under the "Outer setting" domain;the "Access to knowledge and information"construct(e.g.,inadequate knowledge and skills to support school physicians to communicate with students or parents)under the "Inner setting" domain;and the"Individuals"(e.g.,needs of parents)domain.Under the "ndividuals" domain,the results of logistic regression analysis of factors about school-aged children’s vaccination showed that higher parental age(OR=0.960,95%CI:0.926～0.996)and parental perceived barriers of vaccination(OR=0.461,95%CI:0.343～0.621)were negatively correlated with schoolaged children’s vaccination;higher parental perceived threat of influenza(OR=1.499,95%CI:1.115～2.016),perceived benefit of vaccination(OR=4.178,95%CI:2.559～6.821),and cues to action about increased influenza-related awareness due to COVID-19 pandemic(OR=1.989,95%CI:1.423～2.780)were positively correlated with school-aged children’s vaccination.The results of structural equation model suggested that,among the four dimensions of the Health Belief Model,perceived benefits affected vaccination intention and behavior most,and had a direct impact on it(standardized coefficient=0.408);cues to action had both direct impact(standardized coefficient=0.214)and indirect impact(standardized coefficient=0.177)through perceived threat and perceived benefits on vaccination intention and behavior;perceived threat had both direct impact(standardized coefficient=0.095)and indirect impact(standardized coefficient=0.148)through perceived benefits and perceived barriers on vaccination intention and behavior;perceived barriers affected vaccination intention and behavior directly(standardized coefficient=-0.151).Conclusion:Overall,the SLIV delivery in Beijing was mature.However,support and training to improve school implementors’ knowledge and skill were limited,and whole planning and coordination of SLIV and critical emergent infectious disease was inadequate.Health beliefs of parents could interact with each other and influence vaccination behavior and intention. |
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