Engaging school communities to prevent exemptions to kindergarten vaccination mandates

ABSTRACT Vaccine hesitancy, or the state of being conflicted about or opposed to getting vaccinated, is a "top 10" threat to public health, according to the World Health Organization. In the United States, vaccine hesitancy among parents has recently emerged as a particular concern because exemptions to kindergarten vaccination mandates have increased almost 50% since the onset of the Covid-19 pandemic. At the same time, national vaccination coverage among kindergarten-age children has fallen. For example, the proportion of kindergarteners vaccinated against measles has dropped below the 95% needed to prevent community-level transmission to 93%, with even lower coverage found in states such as Georgia (88%), Wisconsin (87%), and Idaho (81%). Despite the public health importance of vaccination mandates, surprisingly little is known about why parents are filing exemptions more often or what communities can do to support parents in ways that prevent exemptions. School-based interventions are a promising way to address this research gap because they can influence vaccine hesitancy and behavior by addressing vaccine-related perceptions, social norms, and practical issues like vaccine accessibility. Thus, we propose to partner with school communities in Georgia, Wisconsin, and Idaho to develop an intervention to prevent vaccine exemptions. In Aim 1, we will characterize multilevel drivers of exemptions to kindergarten vaccination mandates. Working with 9 school communities with high exemption rates, we will use ethnographic methods, including observations and in-depth interviews, to understand the reasons for rising exemptions. In Aim 2, we will develop a multilevel intervention to reduce vaccine exemptions, in partnership with school communities. Using the participatory method of group concept mapping, we will collaborate with parent partners and our school health advisory board to prioritize targets for our intervention. Together, we will develop intervention components drawing from evidence-based strategies for increasing vaccine uptake. In Aim 3, we will pilot the vaccine exemption intervention in partnership with school communities. We will iteratively deliver and adapt our intervention in our 9 study schools over two years. Our multimethod evaluation will examine pre/post- intervention changes in intermediate outcomes related to vaccine perceptions, social norms, and practical issues. To guide future implementation efforts, we will also evaluate implementation outcomes such as acceptability, reach, and delivery cost. Exploratory analyses will assess changes in exemption rates and vaccination coverage. The proposed study is designed to further the ARISe network's goal of advancing the science of immunization services by providing actionable data and scalable solutions to the growing problem of exemptions to kindergarten vaccination mandates. If successful, this research will lay the groundwork for a future cluster randomized effectiveness-implementation trial to scale up our intervention and further evaluate its impact on exemption rates and vaccination coverage.