Optimising Informed Consent in School-based Adolescent Vaccination Programmes in England: A Multiple Methods Analysis

"The process of obtaining informed consent for immunisation provides opportunities for discussion and exchange of information to enhance understanding and strengthen trust in vaccination programmes."

Communication is key to ensuring that parents and adolescents are in a position to make informed decisions about vaccination. A "relational approach" to obtaining informed consent, which recognises that individuals are interdependent and embedded within social contexts, is challenged within school-based immunisation programmes, where health professionals have limited opportunities for face-to-face interaction with parents and to some extent adolescents. This research investigated the process by which consent is obtained in the English school-based adolescent immunisation programme, with the aim of understanding existing challenges and identifying pathways for optimising consent processes.

The World Health Organization (WHO) categorises current vaccination consent practice for 6-17 year olds in 3 ways: (i) written consent - parent/guardian complete form to give consent; (ii) verbal consent - parent/guardian give verbal consent after being informed; and (iii) implied consent - (opt-out) the choice to refuse consent. In England, increased support is being given to the practice of adolescent self-consent, not only for Meningitis ACWY and booster vaccines given to 14- to 16-year-old adolescents but also for the human papillomavirus (HPV) vaccine given from age 12 onwards.

In England, the primary means of communication between immunisation teams and parents and adolescents is by sending out invitation letters with accompanying consent forms and, in some cases, an HPV vaccine information leaflet. Some teams complement this with immunisation information sessions in schools for pupils, but none offers anything similar for parents. Parents are provided with contact details for the immunisation teams so they can ask questions and obtain more information.

The study combined data from 2 sources: (i) interviews with immunisation providers/managers and a review of consent forms, (ii) analysis of survey data of parents and adolescents in relation to vaccination attitudes.

According to service providers, the most common parental concern was the perception that if they assented to their daughter's receipt of the HPV vaccine, they were indirectly condoning promiscuity. A few service providers also noted a decline in the uptake of the second dose of HPV vaccine in their areas and associated this with increased negative media coverage. They observed that awareness about HPV vaccination had decreased over the last few years.

Notably, the tracking survey showed that, if parents had previously seen a leaflet about teenage vaccination (leaflets suggested adolescents should talk to their parents about vaccination), they were more likely to discuss it with their child (39% who had seen at least one leaflet vs 32% overall).

The tracking survey also highlighted that only 37% (184/498) of parents whose child had been offered immunisation were aware that their adolescent had the right to make their own decision about immunisation. In addition, over half of adolescents preferred their parents to lead in the decision-making. Perhaps as a result, there was rarely any disagreement between young people and their parents over immunisation decisions. However:

• In cases where students provided a clear rationale for not wanting to be immunised, nurses would respect their wishes (even if the parents had provided consent) and advise them to get back in touch if they changed their minds. Clinic mop-up sessions were viewed as better places than schools for allaying fears and addressing individual needs.
• In cases where the young person wanted to be vaccinated but the parents disagreed, the nurses reported advising these students to talk to their parents and then approach the immunisation team again when they returned for the next set of adolescent vaccinations.
• Nurses sometimes needed to negotiate situations where adolescents' cultural heritage may inhibit their ability to provide self-consent and where parents and adolescents disagree about consent.

The immunisation teams also described the dissemination and retrieval of consent forms as logistically complex and resource intensive. The active involvement of schools and nominated school staff who supported the programme was described as critical to increase consent form return rates.

The researchers explore some possible solutions to the logistical and practical issues their study highlights - challenges that can have a negative impact on uptake in school-based programmes. A few suggestions:

• Promote shared learning by means of forums such as communities of practice regarding the role technological solutions could play in improving vaccine uptake - e.g., via the development of electronic consent systems.
• Ensure that consent forms refer parents and adolescents to the appropriate information on the vaccine and avoid non-essential questions. (Streamlining consent forms by promoting the use of national templates and ensuring that these either reference or are disseminated with information leaflets could help.)
• Explore and evaluate creative educational tools like an HPV comic book developed by Katz et al. and a web-based HPV information website in order to overcome challenges associated with finding time in school schedules to deliver vaccine education.
• Critically examine strategies such as the use of social marketing to promote adolescent immunisation and the formation of citizen juries to increase parental and adolescent engagement with immunisation.
• Provide nurses with regular training and access to up-to-date information materials so they can be proactive in responding to questions about adolescent immunisation.
• Delve deeper into the issue of self-consent by conducting additional research, training, and reflection to help health professionals gain more confidence not only in assessing competency to decide but also in building adolescents' skills and knowledge to make immunisation and other health care-related decisions.

In conclusion: "There is a need to streamline the logistics and enhance the practices involved in communicating information about adolescent vaccination and obtaining consent for adolescents' participation in school-based immunisation programmes. Most young people rely on parental guidance and resources should be provided to stimulate discussion and enhance immunisation literacy. This may increase adolescents' capacity to make positive choices as they gain more responsibility for their health. Health professionals also need support in assessing and developing adolescent capacity for making autonomous decisions about vaccination."