Lillvis Denise F, Willison Charley, Noyes Katia
Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 77 Goodell St., Ste 220, Buffalo, NY, 14203, USA.
Department of Health Care Policy, Harvard Medical School, 180A Longwood Avenue, Boston, MA, 02115, USA.
BMC Health Serv Res. 2020 Jul 23;20(1):683. doi: 10.1186/s12913-020-05550-6.
In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability.
We conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring).
There was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring).
The immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.
2015年，密歇根州实施了一项规定，要求家长在放弃强制儿童疫苗接种之前，参加当地卫生部门（LHD）举办的教育课程。本研究运用规范化过程理论（NPT）评估项目实施情况，识别对忠实度和可持续性的潜在威胁。
我们对16个当地卫生部门参与这些教育项目的人员进行了32次半结构化访谈。参与的当地卫生部门是从分层的代表性样本中选取的。一名访谈员使用半结构化访谈指南进行所有访谈；两位作者根据NPT框架（即意义建构、参与、集体行动和反思性监测）对访谈记录进行编码和分析。
对于这项新规定及其产生的项目的利益相关者是谁，缺乏共识（意义建构）。也许正因如此，大多数当地卫生部门在规划过程中没有征求关键利益相关者群体（即学校、医疗服务提供者、社区利益相关者）的意见（参与）。虽然大多数受访者将提供教育和信息确定为目标，但一些人确定了更具挑战性的目标，即说服对疫苗犹豫不决的家长为孩子接种疫苗。对于谁应对豁免教育项目的目标负责，看法也存在一些差异（集体行动）。当地卫生部门很少进行正式的项目评估，不过有些部门会进行非正式的员工汇报。此外，进展特别顺利或特别糟糕的课程令人印象深刻（反思性监测）。
免疫豁免教育项目可能面临无法完全融入当地卫生部门日常工作的风险，这可能会损害其长期有效性和可持续性。地方和州一级的管理人员应持续监督，以确保该项目忠实执行。由于该项目依赖于给家长带来不便来鼓励他们为孩子接种疫苗，任何捷径都会破坏其成功。
