Demonstrating an immunization compliance strategy

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Lack of immunization compliance is commonly due to lack of awareness, according to USF College of Public Health’s Dr. Jill Roberts, assistant professor in the Department of Environmental and Occupational Health.

Roberts’ new research, “An Evidence-Based Project Demonstrating Increased School Immunization Compliance Following a School Nurse-Initiated Vaccine Compliance Strategy” is published in The Journal of School Nursing.

She described a successful three-stage strategy to increase school immunization compliance at a Northern Indiana high school.

The doctor gave vaccination needle .

“The school is interesting is because the area is underserved,” Roberts said. “There is a high migrant population and high level of poverty, so some of the more advanced methods of reaching out to people to increase immunization rates aren’t going to work here.”

According to Roberts, relying on social media, email or text reminders—methods more currently used—will not work in a community that faces limited access to cell phones.

Using an evidence-based strategy, school nurse Wendy Swallow employed a three-step process to communicate with parents of teens who were not in compliance.

First letters from the school nurse were sent home with students indicating lack of compliance. The next stage involved a second letter with information from the Indiana State Department of Health, appointment information and a copy of the student’s immunization record.

“It’s one thing to say you need a chicken pox vaccine, but it’s another to say ‘Here’s where you can get it and here’s where you can get it for free,’ so including that information and putting all those factors together made compliance go way up,” Roberts said.

In the final stage, letters were sent home via email and phone calls were used for follow-up. In some cases, Roberts said, in person visits were made if no phone numbers or emails were listed.

Each letter sent home with students included an explanation of exclusion and a date the exclusion from school would apply, according to Roberts.

“Parents don’t know the immunizations are missing,” Roberts said. “But, a bigger thing is they don’t know the consequences of missing immunizations, so if the student is not immunized for a particular disease, they can’t come to school.”


Dr. Jill Roberts

Only 66 percent of students were in compliance pre-intervention. That number increased to 99.6 percent post-intervention, a rate that exceeds national and state averages, according to Roberts.

“Education is so important on this, so that’s why we sent those notes home, with information on the vaccine and the disease it prevents,” Roberts said.

Roberts said schools play an important role in protecting the community from vaccine-preventable diseases.

“For some diseases like influenza your vaccination rate at school can be low, but for measles you need 95 percent compliance to prevent the spread,” Roberts said. “Schools have to protect the community and themselves too, it’s filled with administrators, teachers, custodians, and food workers who also need protection too.”

Roberts said as children become older, regular check-ups decrease, which also impact vaccination compliance.

She said school nurses play an important role in addressing vaccination compliance.

“They are the front line person to actually talk with the teens,” she said.

In fact, Roberts said surveys have shown that parents are more likely to trust health advice when it comes from the school nurse.

“So, if the school nurse is the one sending the note saying their child isn’t vaccinated, they see it as important,” she said.

She said she plans to continue examining the role of the school nurse in vaccination and preventing disease.

State vaccination rules vary, but exclusion of students not in compliance with immunization recommendations is common, according to Roberts.

“If a school has a case, or the community has a case, of a vaccine preventable disease, they can exclude everyone that isn’t vaccinated to stop the spread,” she said.

To learn more about immunization requirements in each state, visits the Centers for Disease Control and Prevention’s State Vaccination Requirements.


Swallow, W., Roberts, J. (2016). An Evidence-Based Project Demonstrating Increased School Immunization Compliance Following a School Nurse-Initiated Vaccine Compliance Strategy. The Journal of School Nursing; pages 1-5.


Story by Anna Mayor, USF College of Public Health