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Paediatr Child Health. 2019 Apr;24(Suppl 1):S54-S67. doi: 10.1093/pch/pxz021. Epub 2019 Mar 29.

The CARD™ System for improving the vaccination experience at school: Results of a small-scale implementation project on program delivery.

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Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario.
Niagara Region Public Health & Emergency Services, Thorold, Ontario.
University of Guelph, Guelph, Ontario.
Dalhousie University, Halifax, Nova Scotia.



We conducted a small-scale implementation study that integrated The CARD™ System (C-Comfort, A-Ask, R-Relax, D-Distract)-a multifaceted knowledge translation intervention designed to improve the vaccination experience at school-within the school vaccination program.


Mixed methods design, including a controlled clinical trial and focus group interviews. The experimental group included five schools whereby CARD™ was implemented. The control group included five schools whereby no changes were made. Focus groups were held at the end of the school year. For nurses trained in CARD™, additional focus groups were held at CARD™ training and after the first round of vaccine clinic visits. Outcomes included vaccination rate at school and adult stakeholder perceptions.


Altogether, 323 students attended study schools. Fifty-five nurses, school staff, and parents participated in 15 focus groups. The school vaccination rate did not differ (P>0.05) between groups for round 1 clinics (76% versus 77%) or round 2 clinics (68% versus 70%). Participants reported acceptability, appropriateness, feasibility, and satisfaction with CARD™. Experimental group nurses were able to integrate CARD™ within usual activities, including clinic planning, student education, and clinic-day set-up and student vaccinations. Students in experimental schools were described by nurses and school staff as more prepared and less fearful during vaccinations. Nurses reported that CARD™ built on their practice; they had higher confidence in their ability to assess pain and fear and higher satisfaction with their ability to manage it. Nurses also reported improved collaboration with students and with each other. All stakeholder groups recommended continuing CARD™. Some additional time was required, primarily related to clinic planning activities and data collection for study purposes.


CARD™ is a promising new approach for improving the delivery of vaccinations at school. Exploration of approaches to increase parental reach and monitoring of vaccination uptake rate over time are recommended.


Knowledge Translation; Pain management; Vaccination

[Available on 2020-03-29]

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