Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial.

Importance: Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake. Objective: To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students. Design, Setting, and Participants: This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination. Intervention: The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination). Main Outcomes and Measures: The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis. Results: A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group. Conclusions and Relevance: In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs. Trial registration: Chinese Clinical Trial Registry: ChiCTR2200062449.

Identifying implementation strategies to address barriers of implementing a school-located influenza vaccination program in Beijing.

BACKGROUND: The school-located influenza vaccinations (SLIV) can increase influenza vaccination and reduce influenza infections among school-aged children. However, the vaccination rate has remained low and varied widely among schools in Beijing, China. This study aimed to ascertain barriers and facilitators of implementing SLIV and to identify implementation strategies for SLIV quality improvement programs in this context. METHODS: Semi-structured interviews were conducted with diverse stakeholders (i.e., representatives of both the Department of Health and the Department of Education, school physicians, class headteachers, and parents) involved in SLIV implementation. Participants were identified by purposive and snowball sampling. The Consolidated Framework for Implementation Research was adopted to facilitate data collection and analysis. Themes and subthemes regarding barriers and facilitators were generated using deductive and inductive approaches. Based on the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool, practical implementation strategies were proposed to address the identified barriers of SLIV delivery. RESULTS: Twenty-four participants were interviewed. Facilitators included easy access to SLIV, clear responsibilities and close collaboration among government sectors, top-down authority, integrating SLIV into the routine of schools, and priority given to SLIV. The main barriers were parents' misconception, inefficient coordination for vaccine supply and vaccination dates, the lack of planning, and inadequate access to knowledge and information about the SLIV. CFIR-ERIC Matching tool suggested implementation strategies at the system (i.e., developing an implementation blueprint, and promoting network weaving), school (i.e., training and educating school implementers), and consumer (i.e., engaging students and parents) levels to improve SLIV implementation. CONCLUSIONS: There were substantial barriers to the delivery of the SLIV program. Theory-driven implementation strategies developed in this pre-implementation study should be considered to address those identified determinants for successful SLIV implementation.

Are public health researchers designing for dissemination? Findings from a national survey in China.

BACKGROUND: Research findings are not always disseminated in ways preferred by audiences, and research dissemination is not always considered a priority by researchers. While designing for dissemination (D4D) provides an active process to facilitate effective dissemination, use of these practices in China is largely unknown. We aimed to describe the designing for dissemination activities and practices among public health researchers in China. METHODS: In January 2022, we conducted a cross-sectional survey in 61 sub-committees of four national academic societies which include a wide range of health disciplines. The sample mainly involved researchers at universities or research institutions, the Centers for Disease Control and Prevention at national or regional levels, and hospitals. Participants completed a 42-item online questionnaire. Respondent characteristics, dissemination routes, dissemination barriers, organizational support, and personal practice of D4D were examined with descriptive analyses. RESULTS: Of 956 respondents, 737 were researchers. Among these researchers, 58.1% had disseminated their research findings. Although there were some variation in the commonly used routes among different groups, academic journals (82.2%) and academic conferences (73.4%) were the most frequently used routes. Barriers to dissemination to non-research audiences existed at both organizational level (e.g., a lack of financial resources, platforms, and collaboration mechanisms) and individual level (e.g., a lack of time, knowledge, and skills, and uncertainty on how to disseminate). About a quarter of respondents (26.7%) had a dedicated person or team for dissemination in their unit or organization, with university researchers reporting a significantly higher proportion than their counterparts (P < 0.05). Only 14.2% of respondents always or usually used frameworks or theories to plan dissemination activities, 26.2% planned dissemination activities early, and 27.1% always or usually involved stakeholders in the research and dissemination process. Respondents with working experience in a practice or policy setting or dissemination and implementation training experience were more likely to apply these D4D strategies (P < 0.05). CONCLUSION: Considerable room exists for improvement in using impactful dissemination routes, tackling multiple barriers, providing organizational support, and applying D4D strategies among Chinese public health researchers. Our findings have implications for structural changes in academic incentive systems, collaborations and partnerships, funding priorities, and training opportunities.

Types and Aspects of Front-of-Package Labeling Preferred by Parents: Insights for Policy Making in China.

The WHO recommends front-of-package labeling (FOPL) to help parents make healthier food choices for their children. But which type of FOPL resonates with parents in China? We performed a cross-sectional study to investigate parental preferences for five widely used formats of FOPL. A multi-stage cluster sampling method was applied to selected parents of students in primary and secondary schools in six provinces and municipalities from July 2020 to March 2021. A close-ended questionnaire was used to collect demographic information, parents' preferences for five FOPL in three dimensions, perceptions of the importance of nutrients labeled on FOPL, and prepackaged foods that need FOPL most. Chi-square tests were used to examine the characteristics among five groups. The results showed that multiple traffic lights (MTL) was preferred by parents, followed by warning labels. Parents thought the most needed nutrients to label were sugar, salt, and total fat. The top three prepackaged foods to label were "baked food", "milk and dairy products" and "sugar-sweetened beverages". Our findings indicate that nutrient-specific FOPL formats with interpretive aids were preferred by Chinese parents. These new findings can help inform the planning and implementation of FOPL in China and help Chinese parents make healthier food choices.

Relationships among weight stigma, eating behaviors and stress in adolescents in Wuhan, China.

Background: The purpose of this study was to examine the relationships among weight stigma, eating behaviors, and stress, as well as to analyze the effect of stress in mediating the association between weight stigma and eating behaviors. Methods: The study involved 1818 adolescents between 14 to 19 years of age and was conducted in Wuhan, China in 2019. Weight stigma, eating behaviors (cognitive restraint, uncontrolled eating, and emotional eating), and stress were assessed by self-report questionnaires. Hierarchical linear regression analyses were used to examine the predictors of cognitive restraint, uncontrolled eating, and emotional eating; the serial mediation models analyses were conducted to analyze the effect of stress in mediating the association between weight stigma and eating behaviors for the whole non-overweight (normal and underweight) and overweight or obese participants, respectively. Results: Hierarchical linear regression analyses showed that experiences of weight stigma significantly predicted uncontrolled eating and emotional eating regardless of body mass index (BMI) (non-overweight adolescents: uncontrolled eating: ß [SE] = 0.161 [0.017]; emotional eating: ß [SE] = 0.199 [0.008], p < 0.05; overweight or obese adolescents: uncontrolled eating: ß [SE] = 0.286 [0.030]; emotional eating: ß [SE] = 0.267 [0.014], p < 0.05); experiences of weight stigma significantly predicted cognitive restraint among non-overweight adolescents (ß [SE] = 0.204 [0.013], p < 0.05). Mediation analyses showed that stress mediated the associations between weight stigma and uncontrolled eating and emotional eating among non-overweight adolescents (uncontrolled eating: indirect effect coefficient = 0.0352, 95% CI = 0.0241, 0.0478; emotional eating: indirect effect coefficient = 0.0133, 95% CI = 0.0085, 0.0186). Conclusions: These findings suggest that non-overweight individuals can still experience weight stigma and its associated negative consequences; the relationship between weight stigma and eating behaviors is modulated by weight status; stress mediated the associations between weight stigma and uncontrolled and emotional eating among non-overweight adolescents.