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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Childhood Vaccination with MMR, Flu, and HPV.

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Strategy. School and Childcare Requirements

Approach. Establish stricter vaccine regulations for school enrollment to support to increase childhood vaccination rates.

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Overview. Establishing stricter vaccine regulations for school enrollment involves mandating specific immunizations for children as a prerequisite for attending public or private schools, often with limited exceptions for medical reasons and religious beliefs.[1] This approach offers a powerful public health tool to increase childhood vaccination rates by creating a strong incentive for parents to ensure their children are up-to-date on recommended vaccinations.[1] A successful public health approach requires careful consideration of several factors.[1] Regulations should be based on the latest scientific evidence and recommendations by public health agencies like the Centers for Disease Control and Prevention. (CDC).[1]. Second, clear communication is crucial to inform parents about the requirements, exceptions, and resources available to assist with obtaining necessary vaccinations. Finally, robust enforcement mechanisms, often involving documentation verification and potential exclusion from school for non-compliance, are essential to ensure the effectiveness of the regulations.[2] Examples of public health programs utilizing stricter school enrollment regulations include initiatives in Mississippi requiring all school children to be vaccinated against measles, mumps, and rubella. (MMR) with limited exemptions, and similar policies in California prompting a significant rise in kindergarten vaccination rates.[3, 4] Peer-reviewed research has shown a clear link between stricter school enrollment regulations and increased childhood vaccination rates.[1] Studies have found that such policies can significantly improve immunization coverage, particularly for essential childhood vaccines, and contribute to overall herd immunity within communities.[5]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work...

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

This strategy is also supported as "Vaccination Programs: Requirements for Child Care, School, and College Attendance" in The Community Guide.

Potential Data Sources. Data to support this strategy can be accessed through:

  • State school immunization surveys
  • School exemption data
  • Public perception and attitude surveys

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Policy. This strategy helps to promote decisions, laws, and regulations that promote public health practices and interventions.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. There are currently no ESMs that use this strategy. Search similar intervention components in the ESM database.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of schools and childcare centers partnered with Title V that adopt and enforce stricter vaccine requirements for enrollment. (Measures policy adoption and implementation)
  • Number of education and outreach activities conducted to inform parents and the public about the strengthened vaccine requirements. (Assesses communication efforts)

Quadrant 2:
Measuring Quality of Effort (“How well did we do it?”)

  • Percent of schools and childcare centers partnered with Title V that have a 100% compliance rate with the new vaccine requirements. (Assesses the strength and consistency of policy enforcement)
  • Percent of school and childcare staff trained on the new vaccine policies, procedures, and exemption criteria. (Ensures staff competency and preparedness)

Quadrant 3:
Measuring Quantity of Effect (“Is anyone better off?”)

  • Number of school districts and local jurisdictions partnered with Title V that adopt stricter vaccine requirements, beyond state mandates. (Measures policy spread and local uptake)
  • Number of partnerships led by Title V formed between schools, health departments, and healthcare providers to support families in meeting the new vaccine requirements that report high levels of engagement. (Ensures coordinated policy implementation)
  • Number of communities that achieve and maintain high childhood vaccination rates and low disease burden as a result of enforcing stricter school requirements. (Shows population-level health impact)
  • Number of states that adopt the stricter vaccine requirements as a model policy for other jurisdictions to follow. (Indicates policy influence and transferability)

Quadrant 4:
Measuring Quality of Effect (“How are they better off?”)

  • Percent of school districts and local jurisdictions partnered with Title V that adopt stricter vaccine requirements, beyond state mandates. (Measures policy spread and local uptake)
  • Percent of partnerships led by Title V formed between schools, health departments, and healthcare providers to support families in meeting the new vaccine requirements that report high levels of engagement. (Ensures coordinated policy implementation)
  • Percent of communities that achieve and maintain high childhood vaccination rates and low disease burden as a result of enforcing stricter school requirements. (Shows population-level health impact)
  • Percent of states that adopt the stricter vaccine requirements as a model policy for other jurisdictions to follow. (Indicates policy influence and transferability)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

[1] Stay Up-to-Date on recommended vaccines. (2023, February 10). Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/index.html

[2] Vaccines and Immunizations | CDC. (n.d.). https://www.cdc.gov/vaccines/index.html

[3] Immunization registry - Mississippi State Department of Health. (n.d.). MS Department of Health. https://msdh.ms.gov/msdhsite/_static/14,0,71,351.html

[4] Department of Public Health. (n.d.). Shots for school. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/School/shotsforschool.aspx

[5] Ginglen, J. G., & Doyle, M. Q. (2017). Immunization.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.