Table 6 Selected quotes from focus group discussions involving public health (PH) staff (n = 15) and school staff (SS) (n = 5)^a

 Relative advantage/disadvantage compared to standard care

(PH12): I really liked how there weren’t as many kids in the room, or all lined up. I think that decreased their anxiety levels too ‘cause if they’re all standing up, 30 of them in the hallway, it’s chaos out there and they kind of feed off of each other…I really, really, really liked having the chairs outside for the students to sit on. Um, like I really think that made a, that made a big difference… I think having us introduce ourselves to them is a really nice thing - just ‘cause then they can, like, familiarize what, kind of like, what to expect when they go into the room or who to expect when they go in the room… We liked the privacy theme, like we’re not all sitting like this at a table. We’re separating Tables. I think that was a good thing that I liked… I really liked the PA announcements - I think that was like really a nice way to support the students: ‘Don’t forget to play your CARD. You’re going to do awesome.’

(PH14): I do like that we actually ask the kids: ‘How anxious are you?’ Before it was just a visual cue that you’re looking for: if they’re visibly nervous, that’s the only time you say, ‘Oh, this kid’s nervous!’ And you get the one out of, I don’t know how many, like the rare child that’ll come in, they’ll be talking to their friends, really nice, you know. Don’t seem nervous at all, but when it comes down to a needle, they’ll pull away. Then all of a sudden, they’re freaking out, so I like that we ask that question.

(SS5): It is worthwhile, I think. Because if something goes wrong with a child at the beginning of the day, and depending on what reaction and other things happen, sometimes by the end of the day there might be more issues for us, as administrators, to deal with, right? And I’m thinking about specific children, but if somebody gets teased at the beginning and then it just compounds as the day goes on, and there are other issues not necessarily related to the vaccination process, then it becomes a discipline issue. So this is just another layer, right? So if we can make this experience as normal and as um… I don’t know, just, then it just makes the rest of the day more normal and non-eventful in a bad way. Less issues.

(PH13): …but um, I did have a student mention how it made him more nervous, the introduction of the CARD system.

 Design quality and packaging (including delivery)

(PH4): When I was going through the PowerPoint, they were completely a hundred percent not interested in that.

(PH2): Four out of fourteen chose to write something (on the CARD pamphlet) and the other ones left them blank….

(PH4): I think a lot of kids seem to forget... two weeks before is too far. Say if your vaccine day was on Monday and maybe if you were to somehow provide a reminder to the students, more than just the email and announcements ‘cause I don’t think a lot of kids even listen to the announcements, in my opinion.

(PH4): For my school the principal sent the email to parents prior to. So, I guess that’s the onus on the parents but how many of them actually then, you know, view the videos and talk to their children about it or did they just have a question of: ‘Is this a concern for you and if it’s not…’ But it may not have, you know, reminded those kids of the options that are available to them.

 Individual stage of change

(PH2): It went well for the two that chose to bring a support person… With the privacy, there was a Grade 9 boy, who, the mum had asked that he be done in privacy. So first two rounds, we did it in privacy. He took out his CARD, and he did not write a single thing on his CARD. So the day of, I pulled him aside down the hall and said, ‘We have done you in privacy the last two times, um is there something you would like today?’ I said, ‘I’m asking because you didn’t write that down. But it’s definitely an option.’ He’s like ‘No that’s fine.’ I’m like, ‘Ok, great!’ And he’s amazing right? And then I was like I’m gonna get a call from mom now, going ‘You didn’t do him in privacy’ right? Then we had one student who in the two previous rounds was quite dizzy afterwards and so he used the ball [i.e., muscle tension]. He’s like, ‘Oh, I think I’m okay.’ I do think that made a difference for him. I mean, who knows, maybe he would have been fine anyway, we have no way of knowing right? …he wasn’t [scared]. I don’t think it is a fear thing.

(PH3): I think I’m putting more value in it now, to be honest. And not that I didn’t before. Um, but seeing the videos again and then actually having the focus group with the administrators and the teachers today, and seeing how, Okay, they’re actually really buying into this. They’re not thinking, <scoffs > ‘whatever.’ You know.

 Patient needs and preferences

(PH2): … It’s really different, if the kid really understands that they can have a say, yeah, if they really buy in and they trust and if they’re honest, it’s a, it’s better way, right? Because you can honor their request.

(SS4): Well I always talk about, even just like in assessment and testing, like the more prepared you are, the less anxious you are, right? So this is a way for them to prepare, ‘cause they’re doing it ahead of time, so it’s not, like: ‘The day is here!’ and it’s, like, scary. It’s more like, ‘OK, we’ve talked about it with the nurse, we’ve filled in our sheets, we know what to expect, it’s not a surprise.’ The more prepared I am, the less anxious…

(PH2): The students didn’t realize they could advocate for themselves. So I think that that’s a strong piece, that they realize: ‘Hey, I have these options and if I’m scared, I don’t have to just sit and take the needle. I have a…’ so it kind of gives an option for that. So, I like that piece.

 External policy and incentives

(PH3): I really liked how (teacher name) was really wanting to implement it in health class and…kind of have the conversation with the kids just on any random things in their health class or whatever. Talking about, you know, using your CARDs, what CARDs would you use for that, and things like that and using the same language… Teaching the kids how to advocate for themselves and how to deal with these adverse situations, how to learn to build the resilience… It sort of elevates us, and it elevates our importance in the school.

(PH4): I’m there to talk about health promotion and healthy eating, active living, and on and on and on. I can talk about vaccines if they want, but that’s not really something that they would approach me about. But having this, um, insight, I kind of feel a little stupid, didn’t think about this before, right? But it’s just pointing it out that these conversations need to be had, it needs to be more of a team approach for vaccination. It’s not them versus us.

 Reflecting and evaluating

(PH3): Sometimes it feels like there’s the vaccinating team and then there’s the school nurse team, right? And I don’t like that division. I hate that division… At three o’clock or whenever the meetings are, (the vaccinating nurses) can come to the beginning of that meeting ‘cause then we’re more of a team… I don’t think it’s wasting time. You’re putting value to the teamwork.

(PH2): I do think that there’ll be more students probably who fill (the CARD pamphlet) in in the fall. I think because most of these students have already received multiple vaccines this year at school, that this is another visit - some it was their first - but the majority of them have seen us already several times. Um, I do think if we start with it, I think it will, um, it will be good.

 Perceived Compatibility

(PH13): I think that (injecting 2 vaccines in 1 arm) will cause more stress to some of the students. (PH12): I think it’ll be a little bit awkward. (PH14): I have to consider the space too, yeah, if the room even allows us moving around the student like that.

(SS5): the coordination, if we take students out from individual classes who have a heightened level of anxiety, that’s just a little bit more prep work... In terms of the planning, we just have to be a little bit more mindful. As to the vaccine day, the times and then if we have the information about the kids then that adds another layer but it’s… it’s doable. It’s just a lot of front-end planning.

(SS3): We’re talking about the anxiety of the needle. What about the anxiety of – ‘I just left math class. There’s an important lesson going on. I’m sitting on this cold bench, waiting. And I’m anxious ‘cause I’m supposed to be in that class learning this concept, and when I go back, I’m behind’… I’d use language with your nurses: ‘Can you work with the admin team for an adapted schedule?’ Yeah - ‘Is it possible to schedule extended homeroom time? Is it possible to extend the health class?’ Ones that are typically with a comfortable teacher that they know well, and it’s not a huge disruption to an academic course where that child that’s anxious for the needle is probably very anxious for missing the big concept.

(SS1): I look at this CARD system and I feel like we’ve been doing this already in this school. Um, we talk to students a lot. We send an email to parents and let them bring an extra snack and juice box, something, a phone, a stuffy, like whatever they want to bring. I feel like we communicated that and let that happen already. This is just, more I think, gonna be really for making sure that they are actually truly aware that ‘I put this in writing, so I really can, and not just my teacher said I can, but it’s in writing.’ So I think it’s just formalizing what we’re already doing in here from the most part.

(PH3): My biggest worry is actually not so much the CARD thing, it’s just the individual [computer] data entry that I find is slowing things down… ‘cause it’s taking a lot more time for students… sitting there a lot longer.

 Actual Compatibility

(PH13): I didn’t find it, um, very different. I was just adding a couple extra questions. I already…from like the task list, I already did everything on there. I was just adding a couple of extra questions, which I didn’t think made much of a difference to me on immunizing.

(SS3): I sat out on the bench with all the students that you have there, there was no one formally in the room to help that anxiety that a few students were exuding. They were on that bench, and that anxiety’s now starting to spread.

 Design quality and packaging

(PH4): The distraction items - they had no interest in even looking at them. So I feel like it wasn’t quite appropriate for their age category.

 Complexity

(PH16): We vaccinated in the library and I really noticed that this is a challenging spot for interruptions. We almost needed to have someone stationed at the door because even though there were two signs on each door and there was an announcement that the library was closed, there were still teachers and students walking in.

(PH16): And I think this school, they didn’t want them with their phones… We could not have chairs in the hallway either, that hallway is narrower than most and it would have been very difficult with class changes and lockers on both sides.

 Adaptability

(PH4): We couldn’t do our introductions in the classroom, just because of how the Grade 9 cohort works. Um, so we did our introductions in the hall…

(PH2): I did staple their CARD to their consent forms because it was my way of identifying who had chosen something versus who had left their CARD pamphlet blank... So it also helped me to say: ‘Do you have a support person? Would you like to go get your support person?’ prior to them going into the vaccination area. So that was my trigger to ask them.

(PH18): You did the debriefing at the school but I found many ideas came at your meetings, you know, after, so that’s a way to keep it, I think, going too because you generally have the weekly meetings.

 Available resources

(PH16): It is really a lot more staff required though. We did 37 grade 9 in about an hour and a half with 5 vaccinators. Then we did about 35 others in about 25 min.

 Reflecting and evaluating

(PH12): We were never told what was written on the CARDs, if they were filled out. Nothing was told to us. So it was kind of blind for us. We don’t know what they’re expecting.

(PH3): Time crunch, and so you’re quickly going through the debrief… it was a little bit short today. I don’t know if we’re maybe focusing on the debriefing as much as we could… Um, maybe we’re not taking it seriously enough, to be honest. Maybe [just ask]: ‘How can we do this? How can we work together as a team? How can we communicate with each other to make this the best experience that we can?’

 Executing

(PH2): The students filled out CARD, but they almost seemed to fill it out almost like they thought it was like a test. And so I thought that was interesting. It proved that they were listening, which is fantastic, but I’m like, that’s really not the purpose of it right? [The next time] after I showed the videos, I handed out the CARD pamphlet, I had all the students put their name on it, and then said: ‘Now think about what you saw, think about what you need, if you think that there’s something you need please put it down. But it’s okay if you don’t, like if you want to leave your CARD blank because nothing resonated to you or you don’t think you need this, that’s okay too.’

(PH3): I couldn’t get the videos to work [school name]… We talked about all sorts of things and we did show the PowerPoint. We just didn’t show the videos, but they still didn’t seem as prepared [as other school].

(PH14): They didn’t really seem interested, I found. Like most of them, they didn’t buy in… As soon as I would ask, ‘Where are you on the fear scale?’ They would say, ‘Around a two or a one.’ And I would say, ‘What CARD do you want to play?’ And he was like, ‘I don’t want to play a CARD, I’m fine.’

(PH4): There was a boy who I know sort of personally, I know his mother… So third time around now, post-CARD, he came in and I asked him what his fear level was, he said he was “two” (out of three) and I said, ‘Okay, well you know, last time this was what we did and you’ve been given some information about things that you can do. Um, so what CARD are you gonna play? What are you gonna do?’ He said, ‘Well, I got my phone.’ Okay, and he pulls out his phone, and he completely ignores me for the rest of the whole appointment, which is good for him, I mean, I’d already done my bit to immunize. And I was like, ‘Okay, d’you just want me to-“Just do it!’ And so there was no anxiety, there was no jitteriness, there was no, you know, moving around. It was just, didn’t have to worry about spelling anything, he was distracted with his phone. He had it there.

(PH3): Due to time constraints today and just being they needed to get some Grade 9’s out of there because they were going (to an event). So, for ease of everything – disruption - we just called all eleven kids down because they were from three different classes. That was a little bit much for the two vaccinators. So, you know, calling four down at a time, or just like you say, double the amount of vaccinators, I think just reinforcing that.

(PH14): For anxious ones, I always explain to them: You know sometimes watching it makes you more anxious, so maybe you can try looking away, maybe that will help you… at the end of it, if they’re gonna look, they’re gonna look.