Parents and teachers’ perspectives on a school-located influenza vaccination program: A pilot study in the Region of Murcia, Spain

ABSTRACT

During the 2022–2023 season, the Region of Murcia (an autonomous community of Spain) introduced the influenza vaccination campaign in children aged 24–59 months with the live-attenuated influenza nasal spray vaccine. To expand coverage, a pilot study was conducted to include the 3- to 4-year population in 24 public schools. The aim of the study was to assess the experiences of parents and teachers involved in the project. This was a psychosocial qualitative study in which information was collected from a cohort of 23 parents and 17 teachers who attended three and two focus group sessions, respectively. A high degree of satisfaction with the school-located influenza vaccination program was consistently reported. The teachers reported creating a friendly environment and acting as companions to support children in the absence of their parents. They also considered the intranasal route, which avoids intramuscular puncture, as a facilitating element that turned the vaccination process into a kind of game. Parents emphasized the importance of vaccination to protect their children, and secondarily, to ensure protection of the family nucleus. Some parents who had their children already vaccinated in the health care center reported preference for the school setting, probably selecting this option in the future. The availability of school-based influenza vaccination promoted greater equity in accessing the vaccine and facilitated family reconciliation. To optimize coverage and minimize potential reluctance, providing the necessary information to parents both before and after vaccination was considered. School-located influenza vaccination was feasible and is a valuable strategy to be implemented in future campaigns.

KEYWORDS:

• Influenza vaccine
• school-located immunization
• focus groups
• parents
• teachers

Introduction

Seasonal influenza virus infection causes significant morbidity and mortality and economic loss worldwide every year. Children younger than 5 years old – especially those younger than 2 years – are at higher risk of developing serious influenza-related complications (such as pneumonia) requiring hospital admission and some of which can be life-threatening and result in death.¹ In a systematic review of global burden of respiratory infections associated with seasonal influenza in children under 5 years of age in 2018, influenza virus accounted for 7% of all acute lower respiratory infection (ALRI), 5% of ALRI hospital admissions, and 4% of ALRI deaths.² According to a meta-analysis published in 2011, a total of one million severe, acute, lower respiratory infections and between 28,000 and 111,500 deaths may be attributable annually to influenza-associated infections in children younger than 5 years, with 99% of these deaths occurring in developing countries.³ Seasonal influenza epidemics in children continue to cause an increase in healthcare utilization and represents a major burden for public health.^4,5

Children have been identified as the largest source of secondary transmission within households and social contact networks.⁶ The important role played by children as a driving force for transmission of influenza is shown by the sequential transmission of maximum infection rates from children to adults,⁷ the apparent interruption of the influenza epidemics during school holidays,⁸ and the reduction of influenza virus transmission vaccinating schoolchildren against influenza.^9,10 Also, monitoring school absenteeism has been proposed as a surveillance tool of influenza activity in the community.¹¹

The seasonal influenza vaccine is the best way to ensure personal individual protection for preventing the development of severe disease, hospitalizations, and potential deaths as well as to reduce the chances of getting the seasonal influenza and spreading it to others. Beginning in 2012, the World Health Organization (WHO) and other international organizations recommend children aged 6–59 months together with other risk groups to be prioritized for influenza vaccination. Recently, WHO´s Strategic Advisory Group of Experts on Immunization (SAGE) renewed this recommendation of influenza vaccination strategy during the COVID-19 pandemic.¹² In Spain, the Commission of Public Health of the Interterritorial Council of the Ministry of Health approved influenza vaccination in children from 6 to 59 months on October 20, 2022, which should be implemented in the 2023–2024 season.¹³ According to these recommendations, three autonomous communities, –Andalusia, Galicia and the Region of Murcia–, included the children’s influenza vaccine in their respective vaccination schedules during the 2022–2023 season. In addition, the Vaccine Advisory Committee of the Spanish Association of Pediatrics (CAV-AEP) publishes, before the start of the influenza season, its recommendations on influenza vaccination in childhood and adolescence. Therefore, in the 2022–2023 season, the CAV-AEP considered that there was sufficient evidence to recommend universal influenza vaccination in children from 6 to 59 months.

On November 2, 2022, the Region of Murcia began the influenza vaccination campaign in the pediatric population aged 6–59 months with the live-attenuated intranasal vaccine, which is the vaccine of choice in children aged 24–59 months as a cost-effective alternative in the absence of contraindications,¹⁴ although the vaccine through the intramuscular route is also used in the population of 6–23 months of age. One of the objectives of the campaign was to achieve 50% coverage, a public health challenge as this was the first year that the childhood influenza vaccine was included in the immunization schedule for this population. Vaccination took place in primary healthcare centers and other usual services in the Region of Murcia. However, after 6 weeks of initiation of the campaign, coverage was lower than expected, so that a pilot school-located influenza vaccination project was implemented in 24 public primary schools, targeting the 1st and 2nd grades of early childhood education (3 and 4 years old) to increase the overall vaccination rates. The intranasal influenza vaccine, in which no needles or punctures are required, facilitates school vaccination in children under 3 and 4 years of age. This school-based influenza vaccination approach has been successfully implemented for several years in some countries such as UK,¹⁵ Finland,¹⁶ Israel,¹⁷ and Ireland.¹⁸

In order to assess the pilot experience of school-located influenza vaccination in the Region of Murcia, a qualitative psychosocial study was designed. The objective was to gather information directly from the parents and teachers regarding their opinions of the different characteristics of the program, including advantages and disadvantages, as well as barriers and facilitators, which would be valuable for effective implementation and expansion of the program in forthcoming influenza seasons.

Materials and methods

Design and setting

A qualitative psychosocial study was designed, with focus groups as the main technique for collecting information. The study protocol was evaluated by the Clinical Research Ethics Committee (CEIC) of Hospital Clínico Universitario Virgen de la Arrixaca of Murcia, but approval was waived due to the quality care characteristics of the study.

The school-located intranasal influenza vaccination with the live-attenuated influenza vaccine (Fluenz® Tetra, AstraZeneca) was implemented as a pilot experience in 24 public schools of different healthcare areas of the Region of Murcia, in which early childhood education was offered. The intranasal Fluenz® Tetra vaccine had granted marketing authorization by the European Commission on September 2013 for the prevention of influenza in children and adolescents from 24 months up to 18 years of age,¹⁹ and is available as a nasal spray containing four active components: two attenuated influenza A strains, based on the influenza A master donor virus and two attenuated influenza B strains, based on the influenza B master donor virus.

For the purpose of the study, parents and teachers from 10 of the 24 public schools that participated in the pilot experience of administering the intranasal influenza vaccine in children under 3 and 4 years of age were selected. These 10 public schools were located in the municipalities of Murcia (469,177 inhabitants, 2023 census), the capital of the Region of Murcia (1,552,457 inhabitants, 2023 census) and Lorca (98,447 inhabitants, 2023 census). The average number of children per class in the participating schools was 23. These children attended the 1st and 2nd grades (3 and 4 years old) in the Spanish public preschool setting. Teachers were recruited by the researchers involved in the implementation of the pilot program, and parents were recruited by nursing personnel and the researchers of the vaccination program. Parents and teachers who had not participated in the pilot program were also recruited to identify possible doubts or reluctances that prevented them from participating. The signed informed consent was obtained from all participants. At the time of recruitment of all the participants, the informed consent form was provided, which was signed and then returned to the researchers.

The influenza vaccination was administered by a school nurse. The school vaccination team is composed by a school nurse and at least one other nursing professional from the health care center. According to the protocol, a pediatrician may also be included in the team when allowed according to the demand for care at his/her health care center. The influenza vaccine was not administered in the presence of parents, but rather in the presence of teachers and the nursing team. Parents, however, attended online meetings for extensive information and clarification of doubts. Vaccination in Spain for target groups of the vaccination campaigns is free and voluntary. The purchase of vaccines is done by the health care system.

Focus groups

Between July and August 2023, five focus groups, each comprising 6–9 participants were organized. All sessions, conducted in Spanish, were held online and had an approximate duration of 2 hours. All participants were volunteers. The distribution of participants is shown in Figure 1. A total of 17 teachers agreed to take part in the study, 8 of which participated in the school-based influenza vaccination program and the remaining 9 did not participate. In relation to parents (which could include indistinctively the father or the mother), there were 7 participants whose children had been vaccinated at school, 8 participants whose children were vaccinated at the primary healthcare center, and 8 participants who decided not to vaccinate their children.

Figure 1. Characteristics of participants in the focus group sessions.

For the purpose of this pilot study, the topics of interest related to school-located influenza vaccination in young children were developed by the authors after previous discussions. They also elaborated a list of the main influenza vaccination-related aspects (Table 1) that were considered of interest to be presented at the focus group sessions. The profile of participants was also considered at the time of selecting and formulation of the study topics. A code book was not created either a priori or during analysis, and to reach saturation was not the goal of the focus group. In fact, focus group sessions consisted of open discussions with exploratory questions moderated by a psychosocial research technician with experience in qualitative techniques. Each group was audiotaped and was later transcribed. Transcripts were then read by the authors for analysis and interpretation. Relevant information was summarized and agreed by consensus by the authors to present a simple decalogue of the teachers’ opinions and a set of recommendations based on the points of view of the parents.

Table 1. Main topics for discussing in the focus group sessions.

Group presentation and context of focus group sessions.

School-located flu vaccination program, main characteristics and objectives.

Evaluation of the experience.

Advantages in favor of flu vaccination in schools.

Disadvantages against flu vaccination in schools.

How did you find out about the pilot study?

Phases with greater involvement.

Pre-vaccination information sessions/training talks.

Informed consent.

Physical site for vaccination.

Post-vaccination experience.

Concluding remarks and recommendations.

Results

Perspectives of teachers

All teachers who participated in the pilot experience of school-based influenza vaccination unanimously reported a high degree of satisfaction, recognizing the positive impact for expanding the coverage of the influenza vaccine and the contribution of their centers.

I am happy for the center, it is an activity that promotes the general interest of the center, related to health activity but that helps improve the educational community and protects it.

This initiative not only advances health-related activities but also contributes to the overall well-being of the educational community, safeguarding and enhancing its welfare.

Teachers also emphasized the safe and friendly environment. Additionally, the intranasal route of vaccine administration, which avoided punctures and needles, turned the vaccination process into a sort of game. The importance of children feeling accompanied was unanimously expressed.

They are in an environment that gives them security, they are surrounded by their teacher’s support, they are calm, I would repeat it …

The young children were hardly aware of the vaccination process. For them, it was not traumatic; rather, it was perceived as entirely normal. None of them cried, and everyone remained remarkably calm. The health workers also handled the situation very well.

… the children came with excitement and also some uncertainty, but the experience was positive because they felt protected by a known figure (the teacher) who gave them security …

I was sitting with them, I felt the responsibility of accompanying them in that process that I would never have imagined would be so quick, so painless… I was very concerned that they were well, calm, being close… And since the side of the little ones that I have experienced, I have to say that the experience was positive and I would repeat it, as a teacher and as a mother …

The possible events after vaccination and the protocol to be followed in case of adverse effects were main aspects of concern for those teachers who did not participate in the pilot study. However, this aspect was not relevant for participants in the pilot study since there were no incidents related to vaccination in their schools. On the other hand, some teachers disagreed with the interference of health-related questions in school educational activities.

Regarding the informed consent, some teachers expressed their reluctance due to the fact that parents could feel questioned if they did not provide the signed consent form, although they recognized that this did not imply a decision against vaccinating children or doing it at the healthcare center.

Some recommendations for actions to take before vaccination would be to organize meetings with parents and activities for children (e.g. Olfatin educational video addressed to 2- to 4-year-old nasal spray influenza vaccination (https://www.youtube.com/watch?v=Mwj23Gynl6E).

They are topics that they could be introduced as a school of parents, because both the vaccination of 6th grade and that of 3, 4 years; It could be included throughout the course within the health week, … a short talk could be given online or in person, taking advantage of other topics, to inform families …

I think it would be ideal for the school nurse to meet with the parents at the beginning of the school year, to report on the process, to send an authorization, etc.; but that they are already informed and that they are thinking about it. I think that on this occasion that part of the information for the parents has been missing …

During vaccination, it was emphasized that the presence of tutors can complement the work of accompaniment and that the classroom itself is an ideal place, but if another space was decided it must be known and familiar to the children. Also, they considered it would be reassuring providing information on what signs should be monitored and guidelines on how to act in case of an incident. Finally, based on opinions expressed by both participating and nonparticipating teachers, a set of recommendations or “decalogue” was proposed aimed to be considered for improving the school-based vaccination process in future influenza seasons (Table 2).

Table 2. Teachers’ decalogue.

Proposals	Content
1. Promote good planning	Notify schools in advance so that the entire vaccination process is well structured.
2. Inform families in advance	Taking advantage of some of the meetings that are already established (the one that is closest to beginning of the campaign). This information should be prepared in advance and address important issues related to process (communicate that the vaccination program will be launched, objectives, organization, support of the tutors …).
3. Informative session	Consider the possibility of an informative session by healthcare professionals focused on medical aspects of the flu vaccine (why it is recommended, what risks there may be, what type of vaccine will be administered, who is not a candidate …).
4. Informed consent	Informed consent forms with clear “yes” and “no” options.
5. Reminder	Design a type of reminder to prevent forgetfulness to provide the informed consent form and at what time should be delivered.
6. Interactions with children	Promotion of previous interactions with children that contribute to turning the vaccination process into a child-friendly process (provision to the schools of specific and adapted activities such as coloring sheets, animated videos, etc.).
7. Presence of tutors	Ensuring the presence of the tutor of each classroom at the time of vaccination and agree, among all those involved in the school, on the ideal physical place for vaccination. Tutors have a crucial role for correctly identifying children.
8. The first child to receive the vaccine	Choosing the first child to be vaccinated and implementing strategies to encourage participation, especially among those with special needs or fears, can contribute to the overall success of the vaccination event.
9. Knowledge of what signs should be observed after vaccination	What to observe after vaccination and how to act in case of an incident. For example, providing a brief written explanation that specifies potential side effects after vaccination and how to act if they occur.
10. Feeling of pride	Promoting the feeling of pride in schools, with information on the results achieved and how vaccination coverage has improved. Involved schools from the first step and provide informed until the last step.

Parental perspectives

Parents who vaccinated their children

The parents who vaccinated their children either at the healthcare center or at school shared the same arguments in favor of vaccination, including the protection of the child as the main benefit, followed by protecting the environment (particularly, the family nucleus as well as classmates, vulnerable people, and the society in general). They also manifested that the immunization of the child prevented the disease and, consequently, the need for a work leave to look after the sick child.

…the vaccine is protection, both for my daughters and for the rest of the classmates, and in the medium and long term, it promotes the development of the immune and biological system …

…I also suppose that by having the children vaccinated, we prevent other children from getting infected, we prevent more people from getting infected…

…besides the complications in minors, you prevent them from being transmitters to grandparents and parents, and that is also important and influences family and work logistics…

…if I prevent her from getting sick for several days, our family organization is better, we avoid everything that comes with it, missing work… there are advantages on all sides.

Another concern was the avoidance of trivializing influenza infection. Although parents did not view influenza as a severe condition as other diseases for which they vaccinate their children, in their discourse, they conveyed that it is a process that can become complicated. Therefore, prevention of infection and minimizing complications was a desirable outcome.

…the flu has a non-serious nature, but it can render you inactive for 10 days. It’s a disease that we have normalized: winter, flu, but we should have a bit of respect for it…

…the vaccine is a shield for the future, not just for that specific moment. With each vaccination as the calendar progresses, it is a shield so that any illness, if encountered, can be milder, strengthening ourselves by relying on science…

The parents who vaccinated their children at the primary healthcare center showed a more proactive attitude since they had to be actively involved in entire process, from requesting an appointment, accompanying the child, and coordinating vaccination with their work schedule. They were also convinced of the need of having their children vaccinated against influenza because vaccines contribute to a better development of the immune system and did not have the perception that the vaccination schedule was overload. When a vaccine is included in the vaccination schedule, they perceived it as an advance supported by scientific evidence. They also cited some vaccinated-related web pages, such as those of the Spanish Association of Pediatrics or the Murcia Heath Council (www.murciasalud.es/web/vacunacion) for consultation. Finally, among those who vaccinated their children at the health center, the majority comment that they would have preferred to do it at the school center and if in the next campaign they are given the option, it will probably be the option they choose.

…the good dissemination campaign they have carried out because it has reached many people in general and from many sources, health messages to mobile phones, information from the school, parent groups… and the fact that it is intranasal, also many people have not been reluctant, I believe that the vaccination rate has been high, although less than those who have had the option of the school, those of us who have vaccinated at the healthcare center have done so proactively, …

I don’t perceive that there are too many vaccines. On the contrary, I understand and trust that the stipulation is based on studies, research, and optimal results, determining the type and quantity of vaccines.

I have consulted the Vaccine Committee of the Spanish Association of Pediatrics. Besides, it’s worth noting that there are individuals who are hyper-specialized in vaccines.

The parents who vaccinated their children at school showed a more reactive attitude. In fact, some of them recognized that without this option, it would have been possible that finally their children may not have become vaccinated. Other comments highlighted the convenience of the intranasal route for rapid and simple administration, the fact that the experience was extremely positive for their children, who returned happily and sharing stories about their vaccination experience.

… it also encourages you to get vaccinated, I did not have it in mind, and the fact that they did it at school is fantastic, because on my own I would not have taken the initiative, not for anything, but because I had no intention. But the fact that it is in the center encourages you to do it …

… for them it was a novelty, all the children went in a group, I think they took it as if they were going on an excursion … it was something positive …

… if they give the vaccine at school, they will fix the world for us, honestly. For children too, if they see that their partner is not crying and such, it becomes easier for them. I asked my son if it had hurt him and he told me no, that it only tickled him, but it was very good. That the enchanted one, that he wanted them to put more …

Parents who did not vaccinate their children

Parents who decided not to vaccinate their children reported several reasons, including the opinion that influenza was not a risky disease and, therefore, influenza vaccination was not indispensable; the negative impact of the COVID-19 vaccine on their confidence in vaccines; and doubts regarding the effectiveness due to the need of updating vaccines to the prevalent strains each season.

… I think some vaccines are super important, for example, I see meningitis as a very serious disease that should be on the vaccination schedule. They are diseases with a lot of risk for children, very bad, but I don’t see the flu in the same way…

… surely next year I would say no unless I am greatly impacted by the information they can give about the severity of the disease in children, but in principle it would be no …

… before you said a vaccine and that’s it, now you are more careful, I understand that people say I am not going to put more chemicals in the body if it is not necessary …

… my children are not ones to get much bronchial issues and such, I didn’t have the need to give it to them. As we have said before, that bombardment with the COVID vaccine, I didn’t want to give them the vaccine at that moment, I decided that I didn’t want to vaccinate them at the moment, my children …

A summary of recommendations for future influenza vaccination campaigns based on parenteral perspectives of vaccinated children is shown in Table 3.

Table 3. Recommendations for future school-based flu vaccination campaigns based on parenteral experience.

Recommendations
Make the beginning of school vaccination coincides with the beginning of the childhood flu campaign. This would have two advantages: Not having to go at the healthcare center “in advance.” Favoring classroom immunity prior to the first flu outbreaks.
Reserve a space at the information meeting at the beginning of the course to communicate that vaccination against flu will be taken place at school.
When providing the informed consent form, it is advisable to include some simple visual information (e.g. brochure) reinforcing the reasons for vaccination and the type of vaccine (intranasal).
Reminders for those who have not provided the informed consent form (e.g. messaging apps).
Provide short and clear information on what should be observed and how to act in case of appearance of any side effect.

In relation to coverage, 1-day school-located influenza vaccination accounted for an increase of 24.6% as compared with 30–35.7% for children vaccinated at the health care centers over a 6-week period.

Discussion

This qualitative study based on information on a school-located influenza vaccination pilot program collected from parents and teachers through open questions in a focus group technique, shows that implementation of influenza vaccination in the youngest between the ages of 3 and 4 years is feasible and was associated with a very positive feedback. As far as we are aware, this has been the first experience of influenza vaccination at school in children of these ages reported in Spain.

Different studies published in the literature have reported a number of benefits of school-located influenza vaccination in children and adolescents, including a decrease in influenza rates and improved school attendance, with indirect protection for unvaccinated children,²⁰ reduction of elementary school absenteeism²¹ and the community risk for influenza (e.g. decreases of emergency care visits),²² a decrease in the incidence of laboratory-confirmed influenza tests and hospitalization,²³ and the possibility of reaching children never previously vaccinated for influenza.²⁴ Although school-located programs for targeted influenza vaccination of school-age children have been extensively adopted,²⁵ there is relatively little information of opinions and experiences of those involved in the process, particularly parents and teachers.

In a systematic review of 11 articles focused on facilitators and barriers of parental attitudes toward school-located influenza vaccination in the United States from 1990 to 2016, facilitators were free/low cost vaccination, having belief in vaccine efficacy, influenza severity, and belief that vaccination is beneficial, important, and a social norm.²⁶ These findings are in agreement with our study, in which parents were consistently positive regarding the protection provided by the vaccine for their children’s health. The perception of convenience in accessing school setting for vaccination²⁶ was also reported in the focus groups discussions of the present study. Barriers identified in the systematic review included cost, concerns regarding vaccine safety and efficacy, adverse effects, and distrust in vaccines.²⁶ Reasons reported by parents who did not vaccinate their children also included doubts regarding the effectiveness of the vaccine.

Interestingly, Cawley et al.²⁷ conducted a systematic literature review of 59 studies to assess strategies for implementing school-located influenza vaccination in children, and found that education, the design of the consent form, and use of reminders can increase parental consent and the number of returned forms, which were also recommended in our study based on parenteral experience. In a randomized clinical trial of text message reminders for child influenza vaccination among 15,768 children at 32 schools, parents in the intervention group received three text messages from the school nurse encouraging influenza vaccination, but the vaccination rates were the same (40%) in the intervention and control groups.²⁸ It appears that more intensive interventions are needed to raise influenza vaccination rates. In another comparative study of two strategies to increase vaccination rates, parent reminder/education combined with school-located influenza vaccination raised vaccination rates (odds ratio 1.27, 95% confidence interval [CI] 1.10–1.47) but parent reminder/education alone did not (OR 0.87, 95% CI 0.75–1.0).²⁹ Based on these studies, it is important to carefully consider the design of effective reminder strategies to enhance the vaccination rate in the school setting, given this has shown to be an effective approach to increase coverage.^25,30 In fact, an increase in influenza vaccination coverage of 24.6% was also observed in our experience. Also, although the rate of influenza vaccination of teachers and parents was unknown, the rate of influenza vaccination in health care personnel (physicians and nurses) last season in Spain was around 50%.³¹

Vaccine safety concerns have been implicated as an important reason by parents who choose not to vaccinate their school-aged children and parental refusal has been especially reported among parents with college degrees and higher socioeconomic status.³² However, the level of education and the socioeconomic status was not investigated in our study. We also found that parents who vaccinated their children referred access and investigating websites and, in this respect, more information about how to interpret media and online information with appropriate website referrals may be include in further tailored-interventions to increase the participation rate in school-located influenza vaccination programs.

Studies of school-located influenza vaccination in children are mostly focused on parental-related issues,^25,26,32 with some of them assessing physician attitudes,^33–35 but evaluation of the teachers’ perceptions of influenza vaccination in preschoolers of their classes is novelty of the study. Teachers unanimously reported a high degree of satisfaction and expressed a sense of pride in recognizing the positive impact of expanding the coverage of the influenza vaccine and the contribution of their centers. However, they also suggested the need to introduce improvements in logistics and planning, the role of tutors, and having information on how to identify and proceed in case of adverse events. Finally, an important aspect of the study was the qualitative characteristics based on the use of a focus group approach, which allow to obtain a more complete and extensive information as compared to other studies in which data on parents’ perspectives were collected using questionnaires.²⁷ Of note, that all participants were volunteers, but we cannot provide data of the response rate as the number of potential participants approached in this pilot study was not recorded. We report the results of this pilot program in the Region of Murcia, which is one of the 17 autonomous communities in Spain. Although competences in health care have been transferred to local governments of each autonomous community including vaccination issues, vaccination programs are not the same. However, vaccination in Spain is not mandatory and vaccines are administered free of charge within the framework of the Spanish public health care system. The Region of Murcia is one of the five autonomous communities in which school-located influenza vaccination is available. The 2022–2023 season was the first in which influenza vaccination in children from 6 to 59 months was introduced in the Murcia Region and, due to logistic reasons, it started late (November 2), the vaccination pilot at school began in December, which is why some of the children had already been vaccinated at the health care center. In fact, the parents most in favor of vaccinating had already done so at the health care center. In the following 2023–2024 season, school vaccination was the first to begin on September 26. We believe that the present experience can be useful for any person in charge of a school vaccination program and especially for those who may be interested in implementing school-located influenza vaccination in their setting as an innovative experience.

On the other hand, this was a qualitative study based on focus groups, although quantitative data could provide a more comprehensive understanding of vaccination rates and factors influencing decision-making. Other interesting aspects such as the long-term impact of the vaccination program on influenza rates, school attendance, or community health outcomes not evaluated in the present experience as they were not the objectives of the study but are of interest for future studies

In summary, school-located influenza vaccination in children aged 3–4 years was associated with benefits of improving coverage and positive attitudes of parents and teachers. This strategy is accessible, allows reconciliation of work and family life, and universalizes influenza immunization in a safe and child-friendly environment.

Acknowledgments

The authors thank all participants in the focus groups and all professionals and parents who allowed implementing this pilot program. The authors are grateful to Cristina Grima (Core Research, S.L.) for the whitebook writing which has been the basis of the present report, Grupo SANED, S.L., for logistic support and Marta Pulido, MD, PhD, for editing the manuscript and editorial assistance.

Disclosure statement

M.Z.M and J.J.P.M declare having received funding from AstraZeneca for training and dissemination activities. M.R.M is full-time employee in AstraZeneca.

Data availability statement

The study data are available from the authors upon request.

Additional information

Funding

This study received external support from AstraZeneca Farmacéutica Spain S.A.