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Researchers at the University of Toronto and The Hospital for Sick Children (SickKids) have teamed up with educators, public health practitioners and Grade 7 students in Ontario to develop and implement a new way to deliver school-based vaccine programs.

The result is the CARD system (Comfort, Ask, Relax, Distract), an evidence-based approach that can be implemented as an in-class game to help students better prepare for vaccination clinics, thereby improving their experiences.

The researchers’ findings, based on a controlled clinical trial involving 10 Niagara Region schools, were published today as a collection of studies in a special open source edition of , the official journal of the Canadian Paediatric Society.  

“Vaccine hesitancy has been identified as a major threat to global health,” says Anna Taddio, who is the lead author of most of the studies and is a researcher at U of T’s Leslie Dan Faculty of Pharmacy. “While school-based programs are an efficient way to deliver vaccines that help protect youth and prevent the spread of illness, many youth have negative experiences due to fear of injection-related pain.

“Fear of pain and needles, compounded by negative experiences, can lead to vaccine refusal and even a longer term reluctance to fully engage health care services throughout life.”

The CARD System allows students to select the coping strategies they want to use during their vaccination by selecting a letter of the CARD system. On vaccination day, nurses explicitly ask students about their level of fear and what “CARDs they want to play” and support them in their choices. For example, students may wish to focus on category “A” and ask to be vaccinated in a private place, or “D” and bring an electronic device to serve as a distraction.  

The results of the clinical trial in Niagara Region showed students’ symptoms improved and increased use of the CARD tools. Students, educators and public health nurses involved were pleased with the approach and wanted to continue with CARD beyond the study. Niagara Region has since implemented the CARD system across all schools in their area.

“CARD is the first knowledge translation tool to integrate all that is known about pain, fear and fainting mitigation into a simple, low-cost, appealing training approach for youth,” says Taddio, who is also a senior associate scientist at SickKids and an internationally recognized expert in children’s experience of pain. 

Those involved with the project say involving youth in the design and development of CARD was crucial because it allowed the tools to be developed based on students’ needs and preferences. “The CARD system is a very intuitive and intentional approach to immunization that enhances the student immunization experience,” says Leslie Alderman, who focuses on vaccine-preventable diseases at Niagara Region Public Health and is a member of the team that oversaw the pilot project.

Earlier this year, the World Health Organization identified vaccine hesitancy as one of 10 threats to global health alongside climate change, antimicrobial resistance and Ebola. Taddio believes that acknowledging barriers to vaccination, like fear and pain, and then designing approaches to address these barriers should help improve vaccine hesitancy over time. For example, talking to students about needles and their fears did not make them more scared or not want to get immunized, according to Taddio.

The pilot implementation project also demonstrated a reduction in fear and dizziness, and resulted in fewer children coming back to the clinic after their vaccination with associated symptoms.

However, the pilot did not show an uptake in vaccinations by students.

“This is not entirely surprising,” says Taddio. “CARD represents a major change in how we deliver school-based vaccines and it will take some time before we can start to measure the impact of CARD on vaccination rates. But it’s also important to point out that we didn’t see a decline in vaccination rates, either.”

The CARD system is now available for use by educators, public health practitioners, students and families at . The project received support from the Canadian Institutes of Health Research.