ALLEVIATING IMMUNIZATION NON-COMPLIANCE DUE TO FEARS OF GRADE 1

PUPILS AND PARENTS OF WEST CITY CENTRAL SCHOOL, WEST I DISTRICT OF

CAGAYAN DE ORO CITY SY 2013-2014

I. CONTEXT AND RATIONALE

Vaccination is a proven method for preventing and eliminating diseases. Such a benefit
cannot go overlooked in a developing country like the Philippines, where illness takes
too great a toll on human life and productivity, and where people simply cannot afford to
be sick.

The present health care globalization services aim to go beyond oral

medication and the advent of vaccination is now implemented to promote quality health
care among our constituents in schools and community quarters. Despite its proven
success, numerous individuals either refuse or delay immunization. Concern about
potential harms is one of the reasons for immunization non-compliance. Parents
perceive that the most common vaccine-related harm is a childs pain from multiple
injections (Kennedy et al, 2011). Parents, then withhold or delay vaccination to try to
avert suffering (Mills et al, 2005)

Injection-induced anxiety and pain are the most frequent adverse effect following
immunization (Taddio et al, 2009). Over 90% of young children exhibit severe distress
during immunization (Jacobson et al, 2001) and both parents and vaccinators admit
they are non-compliant with childhood immunization schedules in an effort to reduce
pain and distress [Woodin et al, 1995, Madlon-Kay et al, 1994]. Compliance has been
shown to decrease as the number of separate vaccine injections being administered
increases [Reis et al, 1997]. Negative experiences with injections lead to the
development of needle fears in some children which are carried into adulthood, and
contribute to health care avoidance behaviors in adults, including immunization noncompliance [Wright et al, 2009].

It is then given with utmost anticipation from public health workers through desirable
approaches that minimize negative manifestations from pain of childhood vaccination
and even for non-adherence and other provoking fears.

II. REVIEW OF RELATED LITERATURE

A. Immunization pain: cause for non-compliance
Outbreaks of vaccine-preventable diseases have been documented to begin in
individuals that refused immunization [Omer et al, 2009] or, due to reduced herd
immunity, among infants too young to be immunized [Diekema et al, 2012]. Thus, the
success of immunization programs is compromised, in part, because fear-induced
avoidance of immunization leads to sub-optimal coverage rates [Guerra et al, 2007].
Pain associated with vaccine injections is a source of distress for individuals of any age
as well as for the immunization provider. For children, being distressed during a
procedure may have a negative impact on the memory of pain.
Research indicates that infants who are exposed to painful experiences develop a
sensitization to future pain and may develop altered responses to future pain. For
example, studies of infant males who were circumcised as neonates found that those
infants exhibited greater pain responses to their 4 and 6 month immunizations than
infants who were not circumcised (Taddio et al, 1997). Rather than developing a
tolerance for pain, if exposed to repeated procedures, children may actually develop a
conditioned anxiety response that manifests as pre-procedural anxiety.
Approximately 10% of the adult population have needle phobia, a condition that
develops in childhood following a negative medical experience involving an injection.
(Wright et al, 2009)
The magnitude of immunization non-compliance due to needle fears has not been well
studied, and may depend in part, on the nature of the vaccine being administered

[Wright et al, 2009]. For influenza vaccine specifically, a review of studies of vaccine
uptake in healthcare workers concluded that 426% of individuals refused vaccination
because of fear of injections [Hofmann et al, 2006].
In a recent study, it was documented that at least 5% of adults undergoing H1N1
vaccination did so because they were guaranteed administration of an analgesic agent
for the needle poke [Taddio et al, 2010]. These data provided the first evidence that
managing injection pain improves vaccination compliance. In this cited study, parents
reported a 30% increase in willingness to be vaccinated themselves if a non-painful
administration method was available and a 40% increase in willingness to vaccinate
their children if influenza was administered in a non-painful manner. Together, these
data further support the hypothesis that vaccine uptake can be improved if pain is
abolished.
Parents reported challenges during their childrens immunization injections, including;
crying, screaming, flailing, and having to restrain children in order to successfully carry
out the procedure. Although the majority reported they had not received education about
mitigating pain, they employed a variety of techniques that were either ineffective or
increase childrens distress. Examples of ineffective strategies include; administering
acetaminophen or ibuprofen prior to immunization, applying ice, or telling children the
injection will not hurt [Taddio et al, 2010]. Examples of strategies that increase distress
include; apologizing, providing reassurance, and empathy [Taddio et al, 2009]. Any
attempt to mitigate pain and distress during immunization must begin with knowledge
about effective techniques. At present, parents employing these ineffective strategies
may be under the false impression that what they do helps their children to cope.

It has been consistently documented that parents are not educated about pain
management during childhood immunization injections [Taddio et al, 2007]. The paucity
of effective needle/immunization anxiety and pain education programs is alarming in
light of the fact that children bear a large burden of pain from immunization injections
due to their repeated occurrence and that the risk of developing needle fears is greatest
in this age group [Taddio et al, 2009]. It is also contrary to efforts to promote discourse
between physicians and parents regarding understanding the reasons parents resist
vaccination and adopting strategies to overcome these hurdles [Diekema et al, 2012]. In
this cited study, most individuals reported they would like to learn ways to effectively
manage injection-related anxiety and pain; hence, efforts should be made to incorporate
this information within current immunization education systems.
If not addressed, the pain and anxiety associated with immunizations can be related to
fear of future procedures, medical fears, and avoidance behaviors including nonadherence with immunization schedules.
Over time, the phobia may become generalized to all medical situations. Adults who
have needle fears or needle phobia tend to avoid preventive medical care for
themselves and may avoid immunizations for their children. The immunization
experience can be anxiety-provoking for the child and for the parents and teachers as
well.
Efforts aimed at minimizing pain in childhood have the potential to promote consumer
satisfaction and trust in health care providers because of more positive experiences for
children and their families.
B. Pharmacologic and non-pharmacologic techniques: interventions for pain and
anxiety during vaccination (Taddio et al, 2010, 2009; Shah et al 2009)
1. Rubbing. Tactile stimulation creates white noise. Pediatric and adult studies
found rubbing or applying pressure to the injection site before and during
injection reduced pain. Toddlers and preschoolers can provide feedback so
rubbing or vibration might be useful (about age 2 and up). Offer to rub or stroke

the skin with moderate intensity on the site, then above injection site during
injection (a parent can help with this). However, do not rub the injection site after
the injection (increases risk of vaccine reactogenicity).
2. Distraction. Systematic review of 4 random-controlled trials (RCT) of 324
children showed age appropriate parent led distraction reduced distress from
about 6 months. However, a reduction in pain has not been clearly shown.
Distraction for reducing pain and distress of other procedures has been found to
be more effective if it involves active participation by the child (e.g., blowing
bubbles, manipulating a game, pointing to an eye spy book). Clinician led
distraction has been shown to be more effective than parent led distraction at
reducing pain (4 studies, 284 children - however children and parents should be
involved in the choosing of the distraction and how it will be used. Child led
distraction is effective for over 4 year olds (choosing and using a toy or
electronic devise). For school-aged children, counting, and non-procedural talk
(favorite movie, etc.) can be used.
3. Breathing techniques. Breathing techniques useful in over 3 year olds to
reduce pain (blowing bubbles, pin wheel/wind mill are both a distraction and
breathing technique). Instruct child to take deep breath in and the blow it out
slowly (tummy breathing), remind or prompt the child during the procedure
4. Parental reactions. Non-procedural talk, suggestions on how to cope, and
appropriate humor decrease childrens distress and pain. Reassurance and
apologies increase childrens distress and pain. However, it is difficult to train
parents to do the right things in the moment, especially if they are distressed
themselves. Two RCTs of parent coaching during immunization (distraction and
appropriate parent behaviors) with 212 children aged 2 months to 2 years. This
resulted in no difference in pain, but some reduction in child distress.
5. Fast delivery/ No Aspiration/ Injection Order. Aspiration and slow injection
add to pain probably because of longer contact time between needle and tissue

and through lateral movement of the needle. Aspiration is not necessary

because vaccination sites are devoid of large blood vessels. When aspiration is
omitted there is no increased risk of harm. RCT of injection technique showed
rapid technique resulted in less pain (1 second for 0.5ml) versus slow technique
with aspiration (up to 9 seconds). One RCT showed giving the more painful
vaccination last decreased overall pain from both injections. More painful
injections include MMR and Previnar.
III. RESEARCH QUESTIONS
As a public health nurse in schools of whom considered to be front-liners in the
field of health and nutrition programs involving medical and clinical procedures,
the researcher is concerned on how to alleviate the level of anxiety, discomforts
and fears among school children, parents and even teachers.
The following essential questions are to be given utmost emphasis:
1. What is the incidence rate of fears and anxieties from vaccination among school
children in grade I classes of West City Central School?
2. What are the possible causes and or reasons relative to the level of anxieties
applicable in school-based settings?
3. What are the strategies that the school administration and the health & nutrition
staff can provide to the school children, students, parents and teachers in
minimizing pain, anxieties and discomforts to the school children, parents and
teachers?

IV. SCOPE AND LIMITATION

This study is limited to Grade I pupils under 6-7years of age in West City Central
School, West I district school situated in Barangay Carmen, Cagayan de Oro
City. The targeted number of grade I pupils to be examined through vaccination
are two hundred (200) pupils with complete immunization records from
barangay health centers and or in private pediatric clinics. The costs of blood
screening and vaccinations is 600.00 per child which led to restrictions on the
number of beneficiaries for thorough examinations. The sponsoring agency is
from the Pediatric department of Northern Mindanao Medical Center
spearheaded by Dr. May Glor B. Demegillo

V. METHODOLOGY
Sampling
A sample school-based vaccination activity used was the Hepatitis B screening and
Booster Immunization of all Grade I pupils from 19 sections of West City Central
School. Grade I pupils aged 6 to 7 years of age who received 3 doses of Hepatitis B
primary immunization were eligible for enrolment in the study. A letter was sent to
parents to retrieve the immunization record of their child. Inclusion criteria were as
follows:
1. those with available immunization record confirming that they had received 3
doses of Hepatitis B vaccine from their local health center;
2. those with written informed consent from parents (Appendix 1 and 2); and
3. those with verbal assent from the child.
Written informed consent was obtained by explaining the details of the study to the
parent/legal guardian in a language that they could understand and then a consent
form was signed by them, if they opted to participate in the study.
Data Collection

Those who were enrolled in the study were subjected to history taking and physical
examination. (Appendix 3) Three ml of blood sample was withdrawn by a
phlebotomist for anti-HBs titer and HBsAg determination. Children who were
identified as having antibody titer of <10 mIU/mL were given a booster dose of
10mcg of recombinant Hepatitis B vaccine (ShanvacB) intramuscularly (deltoid).
Parents were advised of possible adverse reactions following vaccination. A repeat
anti-Hbs titer determination was done 4 weeks after the booster dose.
Ethical Issues
The research protocol was approved by the Ethical Review Board of Northern
Mindanao Medical Center (NMMC)
Plan for Data Analysis
VI. WORKPLAN
OBJECTIVE

Expected Output

1.To determine incidence rate of

anxiety on pre & during vaccination

60-70% of the targeted

number of pupils of 200
will be screened &
immunized
Causes/
reasons
of
anxiety
will
be
determined
through
observation and direct
interaction during blood
extraction
and
vaccination
Sch. Administration staff
and parents participated
in the advocacy of HepB
screening & vaccination

2.To
determine
possible
causes/reasons of anxiety among
school children during vaccination.

3.To
identify
a
child-friendly
approach in reducing anxieties &
pain during vaccination.

VII. COST ESTIMATES

No expenditures were made and done by the researcher related to this study. The
respondents however are required to pay P 600.00 to the sponsoring agency,
Northern Mindanao Medical Center (NMMC) to cover for the costs of blood screening
and vaccinations.
VIII. ACTION PLAN
OBJECTIVE

ACTIVITY

PERSONS INVOLVED

1.To
determine
incidence
rate
of
anxiety
on
pre & during
vaccination

-Conduct
Hepatitis B
screening &
Booster
Immunizatio
n
among
Grade
I
pupils under
6-7years of
age.

*School Health &

Nutrition staff
*NMMC
Pediatricians/Medical
staff
*Class Advisers
*Phlebotomists from
NMMC Blood Bank
*WCCS
administrators/Distri
ct In-charge

Oct.Nov.
2013

-Render
series
of
orientation
on
HepB
screening &
vaccination
in all grade I
classes.

*WCCS
school
nurses
*NMMC Pedia Dept.
Medical staff
*School Principal &
teaching staff
*Parents

Jan.March
2014

2.To
determine
possible
causes/reaso
ns of anxiety
among
school
children
during
vaccination.

3.To identify a
child-friendly
approach in
reducing
anxieties
&
pain
during
vaccination.

IX. LIST OF REFERENCES

TIME
FRAME

January
-July
2014

RESOURCES
NEEDED
*Anti-HBs titer
*HBsAg
*syringes
*cotton
*plaster
*alcohol
*bond
papers
for production
of
communication
materials

*School Memos
*Communicatio
n letters for
Parents

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