Immunising the Invisible: The School-based Immunisation Program for young people with disability in specialist school in Victoria, Australia

© 2020 Jennifer Nicole O'NeillImmunisation reduces morbidity and mortality, and affects equity in health. This is evident between countries and regions, and within them, where there may be pockets of the population vulnerable to under-immunisation that experience more barriers to preventive health care. People with disability are one such group that are largely invisible in research and immunisation policy decisions. In particular, there is a paucity of data on adolescent immunisation in young people with disability in Australia. In Australia, students receive adolescent immunisations through the School-based Immunisation Program at 12 to 13 years of age. Vaccine uptake data for the majority of young people with disability attending specialist schools are not included in aggregate immunisation reports. Therefore, there is a clear need for coverage data, as well as qualitative research to clearly identify the barriers and enablers to immunisation for young people with disability in specialist schools. The aim of this thesis was to explore and describe acceptance and delivery of immunisation in specialist schools for young people with disability in Victoria, Australia. The research was designed as a mixed methods qualitative dominant and sequential explanatory study, with a quantitative phase followed by a qualitative phase. Phase One consisted of a prospective cohort study that aimed to measure the uptake of immunisations in specialist schools for young people with disability in Victoria, Australia. Data were collected on immunisation days in the 2017 school year from specialist schools in Victoria in order to determine uptake of diphtheria-tetanus-pertussis (dTPa) and human papillomavirus (HPV) immunisations in eligible students. Demographic data, motor and intellectual function of students, and reasons for non-receipt of dTPa and HPV vaccine were recorded using REDcapTM software and were analysed using descriptive statistics. Results from this study found that of the 28 specialist schools that participated, dTPa was received by 63% (237/374) of participating students, and HPV dose 1 (HPV1) was received by 66% (76/114) of female students and 67% (174/260) of male students. Three doses of HPV were received by only 41% (100/241) of students. The main reasons for missed immunisation were absence from school, lack of consent and inability to immunise due to the student’s behaviour and/or anxiety. Comparative data during the same time period for students in mainstream schools demonstrated significantly higher uptake, at 89% for dTPa and 75% for three doses of HPV, confirming under-immunisation of students in specialist schools. Phase Two consisted of an in-depth qualitative inquiry that utilised the Socio-Ecological Model (SEM) as a framework, which aimed to determine barriers and facilitators of immunisation for young people with disability in specialist schools in Australia. Data collection included 10 observations of specialist school immunisation sessions, 40 in-depth semi-structured interviews and two focus groups with key stakeholders, including representatives from state government, local government immunisation teams, specialist schools and parents of students. Data were coded and themed using Reflexive Thematic Analysis, as described by Braun and Clarke (2006; 2019). Five main themes were identified: an invisible population, searching for support, going the extra mile, competing priorities and trust takes time. The intersection of the themes across layers of the SEM varied, demonstrating the complex nature of the issue and the need for this multilayered approach. The integrated inferences from these two phases resulted in key recommendations. These recommendations include: ongoing rigorous coverage data recorded for ungraded schools; stronger central support for immunisation teams; a review of the immunisation funding model to reflect the extra work and resources required in some schools and to provide for increased follow-up and catch-up; clear guidelines for the use of restraint during immunisation in specialist schools; and a referral pathway for students with disability who cannot be immunised in the school setting. This thesis has generated new knowledge by establishing that young people with disability in specialist schools in Australia are missing their adolescent vaccinations, and that there are unique barriers to immunisation in this school setting. Phase One provided the first Victorian figures on coverage of adolescent immunisations of young people with disability and Phase Two constitutes the first qualitative research that has been conducted internationally on immunisation in children or young people with disability. Recommendations arising from the integration of findings from both phases have the potential to be translated into policy and practice, and thereby have a significant impact on the health and health equity of young people with disability