Effect of CARD (Comfort-Ask-Relax-Distract) on acceptance of school-based vaccinations: A controlled before and after...

Injection-related pain and fear are common in children undergoing school-based vaccinations and contribute to vaccine refusal. The CARD system (Comfort Ask Relax Distract) includes interventions that reduce pain and fear. This pragmatic study evaluated CARD's impact on school program-related vaccine uptake using a controlled before and after study design. Altogether, 67 Public and Catholic schools receiving vaccination services from a public health unit in Ontario, Canada, were included. Schools were ranked by vaccination uptake in grade 7 students in 2022-2023. The bottom 29 schools were allocated to CARD (intervention) and the remainder to control for 2023-2024 school vaccinations. In CARD schools, nurses educated students at school and information about CARD was added to vaccine correspondence for parents. On vaccination day, nurses applied interventions designed to improve coping. Vaccination coverage outcomes were assessed for 3 targeted vaccines - human papillomavirus (HPV), hepatitis B (HB), and meningococcal conjugate-ACYW (MCV). Baseline (2022-2023) vaccine coverage was lower (p < .01) in CARD-assigned schools (n = 1478) [vs. controls (n = 1729)] for all vaccines. During the study period (2023-2024), coverage increased (p < .001) within the CARD group (n = 1403) for HPV (+9.8%), HB (+8.1%), and MCV (+5.3%). Coverage remained the same or decreased within the control group (n = 1877): HPV (-1.1%; p = .50), HB (-4.4%; p = .004), and MCV (-2.7%; p = .03). In 2023-2024, vaccination uptake did not significantly differ between groups. Overall uptake in all schools was higher in 2023-2024 vs. 2022-2023 for HPV (+4.0%; p = .001). This study demonstrates effectiveness of CARD for increasing vaccination uptake. Evaluation of impact in other geographical regions is warranted.