Impact of Educational Interventions on Adolescent Attitudes and Knowledge Regarding Vaccination: A Pilot Study

Current immunisation levels in England currently fall slightly below the threshold recommended by the World Health Organization (WHO), and the 3-year trend for vaccination uptake is downwards. Some have suggested that public health efforts to address issues of vaccine hesitancy (as opposed to active resistance) may prove beneficial in terms of maintaining coverage. Given that attitudes towards vaccination seem to be firmly held by adulthood, and if beliefs are often formed during childhood and early adolescence, then strengthening positive messages about vaccination through school-based educational programmes may influence young people's future vaccination decisions about their own children. This study assessed both digital simulation-based and traditional educational interventions with young people in England to assess whether or not these can affect their attitudes towards vaccination or their level of confidence in their knowledge of vaccination.

This quantitative/qualitative data collection approach was shaped by the Health Belief Model (HBM), which focuses on understanding attitudes towards a health topic by investigating the impact of "concepts" on health beliefs, including perceived susceptibility and severity (e.g., to a disease), perceived benefits of an action such as vaccination, perceived barriers to the action, cues to action (e.g., a letter from a doctor), and sources of information in vaccination decisions. This study used the HBM to explore the attitudes of teenagers towards vaccination during the initial research stages, using interviews (n = 14). An initial discussion task incorporated "role-play" and decision-making; participants were asked to imagine that they needed to decide whether or not to vaccinate their child against measles. Interviews were then conducted to data saturation, and yielded 6 main themes. These themes informed the design of the attitudinal survey, discussed below. In addition, the HBM underpinned the development of the initial interview schedule and discussion questions.

Participants (n = 63) in the intervention study were recruited from a secondary school in North West England. Most of the participants were 15 years old, just over half of the participants were male, the majority of participants were White British, and participants largely reported as being either Christian or non-religious. The researchers performed an initial survey of all participants using a questionnaire in order to establish their attitudes towards vaccination, their confidence in their knowledge of vaccination, their information needs, and their views on personal choice concerning vaccination. This established baseline scores for each individual.

The group was then divided into 3 sub-groups: Group A (n = 26) received a digital game-based resource (n = 26), Group B (n = 21) received a traditional PowerPoint-based presentation on infectious diseases, and Group C (n = 16) received no intervention. With Group A, the researchers trialled an interactive software package called SimFection, which uses computer simulations to illustrate concepts such as herd immunity, infectivity, mortality rates, the effect of migration, and ring vaccination (which are all covered in current school curricula). SimFection is based on the SimZombie package, which has been used for teaching and public engagement. This approach is based on the "health games" model, which uses software, board games, or other activities to develop understanding of health-related issues. One example is the "Re-mission" game, a digital health intervention that has been shown to improve adherence to medical treatments and knowledge and understanding of cancer in young adults and adolescents with cancer.

Initial data collection was conducted in January 2016, and 6-month follow up assessments were conducted in July 2016. The questionnaire delivered before and after the interventions, and after a 6-month period, comprised 2 sections: an attitudinal survey (8 questions, using a Likert scale), and questions on information needs and personal choice (6 questions). The engagement survey, completed only after each intervention, comprised 6 questions.

Chi-squared analysis revealed no statistically significant difference between the 3 groups after the intervention was delivered (p-0.115, degrees of freedom (df) = 4). In addition, there was no statistically significant difference between the groups after the 6-month follow-up (p = 0.116, df = 4). Both intervention groups actually shifted to a less enthusiastic attitude towards vaccination, while the control group moved to a more sympathetic position. However, the group receiving the presentation-based intervention saw a sustained uplift in confidence about information needs, which was not observed in the simulation-based intervention group.

In terms of engagement with the interventions, using Mann-Whitney analysis, the researchers observed no statistically significant difference in responses to questions on this subject across the intervention groups, apart from Q1: "I found the session informative", where more participants from the digital group agreed with the statement than in the presentation group (p = 0.04, df = 2). Qualitative written feedback received from participants focussed on a desire for more information about vaccination and its possible side effects, and a need to use a wider range of example diseases.

Pre-intervention attitudinal scores were generally positive (simulation-based intervention group: 31.4/40; presentation-based intervention group: 32.5/40; control group: 31.5/40), suggesting that this group was already well-disposed towards vaccination. According to the researchers, this may account for the fact that there was no significant difference in attitudes after receiving the intervention.

Thus, the main conclusion of the research is that educational interventions focused on vaccination do not have a significant effect on the attitudes of young people. These findings are consistent with previous work on vaccination interventions designed to reach adults, which have shown limited effectiveness and that can actually reduce intention to vaccinate. Interestingly, there was no statistically significant difference between the digital resource group and the presentation-based intervention group in terms of engagement. This has significance for the current debate about the value of so-called "games for health".

The main limitation of this study was the sample size. For this reason, it is possible that the study is underpowered. Along those lines, some questions have emerged from this work:

• Would vaccination interventions have a more significant effect on participants with more negative initial attitudes towards vaccination?
• What, if any, effects do ethnicity and religious background have on the effectiveness of educational vaccination interventions?
• If teenagers' attitudes towards vaccination are generally positive, but vaccination uptake is lower than the recommended level set by the WHO, what other factors are negatively influencing attitudes towards vaccination between adolescence and parenthood?

In terms of the wider area of research, this project has demonstrated the difficulty of changing attitudes when using short-timescale interventions. This might suggest that more in-depth and/or longer-term interventions are needed to change complex attitudes such as attitudes towards vaccination.