Table 7 Suggestions for CARD™ refinement for future cluster trial

Leadership roles

Foster a positive implementation climate by undertaking the following activities:

• Frequent communication between formally appointed implementation leaders and project leaders regarding progress and issues related to implementation

• Checklist for vaccine coordinator (manager overseeing school immunization program at CHC level) articulating supervisory role in staff training and CARD™ implementation

• Process for regular data transfer (e.g., weekly) to researchers for ongoing data entry and feedback to support ongoing debriefs and planning future clinics

• Ensure adequate staff to carry out CARD™ (plan for activities to take longer due to learning curve and additional time involved in immunization planning activities)

• Manage staff anxiety from CARD™ and concurrent practice changes (e.g., direct data entry)

• Regular communication (newsletter, infographic, Q&A) regarding study progress and results to engage and inform staff

• Solicit structured feedback from external stakeholders (e.g., school staff)

• Prepare and oversee additional training and resources with project leaders to support staff with CARD™ implementation, as specified further below

Booster training^a for staff

Provide additional training and support (overseen by the vaccine coordinator and supported by the formally appointed implementation leaders) to improve staff understanding, buy-in and self-efficacy, including:

• Rationale and overarching goal of CARD™ and alignment with organizational mission/values

• Re-review of educational materials (e.g., training videos)

• Revised and expanded resources for use (e.g., invitations to principals for participation, scripts for interactions with students, class introductions, reminder prompts on data forms)

• Detailed instructions regarding data collection procedures (e.g., use of pre-numbered data collection forms, and other checklists)

• Role of staff feedback to inform revisions and refinement to implementation processes and documentation, as specified further below

Specific instructions in implementation processes and checklists

Provide more instruction (including sample pictures/illustrations) regarding how to tailor some components of CARD™ to the local context, including:

• Bundling needed materials and supplies (e.g., table posters, door signs, distraction kits, extra data forms) ahead of time, in a grab and go bag, for easy retrieval

• Leveraging existing meetings with school staff to include information about CARD™ (e.g., annual anaphylaxis training)

• Keeping the number of students in pre-immunization waiting area to a reasonable amount (about double the number of immunizing nurses)

• Addressing student anxiety in the pre-immunization waiting area. Suggestions: distraction kits, adult supervision

• Providing seating in pre-immunization waiting area to increase student comfort

• Adding more instruction about effective separation of workstations, obscuring equipment from view, and positioning students so that they cannot see one another during immunization

• Diversifying distraction items in the distraction toolkit so they are suitable to different students

• Including information about injecting two vaccines in the same arm

• Using regular staff meetings to continue conversations about CARD™ implementation with all team members go inform additional revisions and refinement to implementation

Revision of data collection forms

Revise the nurse feedback form to maintain fidelity and accuracy in documentation, including:

• Adding reminder prompts for several core components of CARD™ performed at the time of immunization (i.e., asking about fear prior to injection, inviting students to play their CARDs, injecting 2 vaccines in one arm)

• Clarifying operational definitions of coping strategies (e.g., verbal distraction, deep breathing, and muscle tension) to reduce potential error and bias in their interpretation by immunizing staff recording data

Revision of student education

Revise student education, including:

• Instructing students that 2 vaccines will be injected in the same arm unless they choose otherwise

• Adding pictures of the immunizing space and waiting area that will be used in the specific school to help prepare them

• Sending reminder to students about immunization day close to the actual date to prevent them forgetting

• Ensuring educational videos play ahead of time (e.g., download videos onto computer, obtain necessary computer adapters, IT support)

• Reducing teaching time around the videos, including removal of cases, to reduce redundancy/overlap with videos; use time to answer student questions

• Encouraging students to bring their own distraction items to ensure they are suitable

• Including a topical anesthetic information form

• Pinning up CARD™ posters around school (e.g., main area, classroom) as a reminder of CARD™

• Providing access to students of their completed CARD™ pamphlets so that they can be reviewed prior to immunization