Cath Jackson

Communicating with parents about vaccination: a framework for health professionals

BackgroundA critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care. We sought to provide a framework for health professionals when communicating with parents about vaccination.MethodsLiterature review to identify a spectrum of parent attitudes or ‘positions’ on childhood vaccination with estimates of the proportion of each group based on population studies. Development of a framework related to each parental position with determination of key indicators, goals and strategies based on communication science, motivational interviewing and valid consent principles.ResultsFive distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%). The goals of the encounter with each group will vary, depending on the parents’ readiness to vaccinate. In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used.ConclusionsHealth professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns. These recommendations are tailored to specific parental positions on vaccination and provide a structured approach to assist professionals. They advocate respectful interactions that aim to guide parents towards quality decisions.

A systematic review of decision support needs of parents making child health decisions

Objective  To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

Applying an extended version of the Theory of Planned Behaviour to physical activity.

This prospective study explored whether extending the Theory of Planned Behaviour (TPB) with additional variables (descriptive norm, moral norm, anticipated affective reaction, self-identity and past behaviour) would account for additional variance in physical activity intentions and behaviour. Four interactions with past behaviour were also investigated. UK college employees participated in this study (n=200, Time 1; n=146, Time 2). Moral norm, self-identity and past behaviour each explained additional variance in intentions, over and above the TPB variables. Past behaviour moderated the impact of descriptive norm on intentions. Intentions, self-identity and past behaviour were significant predictors of behaviour, as measured by a self-report physical activity questionnaire. To increase physical activity, interventions might target moral norm and self-identity for physical activity. Focusing on positive descriptive norms might benefit sedentary individuals. The significant role of past behaviour is less useful in directing interventions.

Evidence, Theory and Context: Using intervention mapping to develop a worksite physical activity intervention

BackgroundThe workplace is an ideal setting for health promotion. Helping employees to be more physically active can not only improve their physical and mental health, but can also have economic benefits such as reduced sickness absence. The current paper describes the development of a three month theory-based intervention that aims to increase levels of moderate intensity physical activity amongst employees in sedentary occupations.MethodsThe intervention was developed using an intervention mapping protocol. The intervention was also informed by previous literature, qualitative focus groups, an expert steering group, and feedback from key contacts within a range of organisations.ResultsThe intervention was designed to target awareness (e.g. provision of information), motivation (e.g. goal setting, social support) and environment (e.g. management support) and to address behavioural (e.g. increasing moderate physical activity in work) and interpersonal outcomes (e.g. encourage colleagues to be more physically active). The intervention can be implemented by local facilitators without the requirement for a large investment of resources. A facilitator manual was developed which listed step by step instructions on how to implement each component along with a suggested timetable.ConclusionAlthough time consuming, intervention mapping was found to be a useful tool for developing a theory based intervention. The length of this process has implications for the way in which funding bodies allow for the development of interventions as part of their funding policy. The intervention will be evaluated in a cluster randomised trial involving 1350 employees from 5 different organisations, results available September 2009.

Does the use of a theoretical approach tell us more about hand hygiene behaviour? The barriers and levers to hand hygiene

Background: Despite many strategies employed to improve hand hygiene, compliance remains low at around 50%. Two reasons have been identified for this. First, implementation strategies are rarely tailored according to assessed barriers and levers to best practice. Secondly there is a lack of explicit theoretical basis for the assessment of these barriers and levers to practice. Aim: This paper reports barriers and levers to hand hygiene and an evaluation of the use of theory in assessing barriers and levers to hand hygiene. Methods: Identification of barriers and levers occurred through interviews, questionnaires and focus groups. In each case two different question schedules were used, one based on psychological theory and the other with no explicit theoretical underpinning. Results: Although there was considerable overlap in the barriers and levers identified using the two schedules there were also marked differences. Conclusions: Identification of further barriers and levers may help us address lack of compliance with hand hygiene. Using a theoretical framework may prompt the identification of barriers that people may not ordinarily report but which have an important impact on behaviour, particularly emotion.

A cluster randomised controlled trial of a web based decision aid to support parents' decisions about their child's Measles Mumps and Rubella (MMR) vaccination

Highlights • The use of decision aids for immunisation decisions is under researched and controversial.• Parents receiving a decision aid or a leaflet had reduced decisional conflict for the MMR decision.• MMR uptake in the decision aid and control arms achieved levels required for population immunity.• Leaflet arm parents were less likely to vaccinate their child.• Childhood immunisation decision aids can achieve both informed decision-making and uptake.

Original Research: AsthmaAdverse Respiratory Effect of Acute β-Blocker Exposure in Asthma: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND β-Blockers are avoided in asthma over concerns regarding acute bronchoconstriction. Risk is greatest following acute exposure, including the potential for antagonism of β2-agonist rescue therapy. METHODS A systematic review of databases was performed to identify all randomized, blinded, placebo-controlled clinical trials evaluating acute β-blocker exposure in asthma. Effect estimates for changes in respiratory function, symptoms, and β2-agonist response were pooled using random effects meta-analysis with heterogeneity investigated. RESULTS Acute selective β-blockers in the doses given caused a mean change in FEV1 of −6.9% (95% CI, −8.5 to −5.2), a fall in FEV1 of ≥20% in one in eight patients (P=.03), symptoms affecting one in 33 patients (P=.18), and attenuation of concomitant β2-agonist response of −10.2% (95% CI, −14.0 to −6.4). Corresponding values for acute nonselective β-blockers in the doses given were −10.2% (95% CI, −14.7 to −5.6), one in nine patients (P=.02), one in 13 patients (P=.14), and −20.0% (95% CI, −29.4 to −10.7). Following investigation of heterogeneity, clear differences were found for celiprolol and labetalol. A dose-response relationship was demonstrated for selective β-blockers. CONCLUSIONS Selective β-blockers are better tolerated but not completely risk-free. Risk from acute exposure may be mitigated using the smallest dose possible and β-blockers with greater β1-selectivity. β-Blocker-induced bronchospasm responded partially to β2-agonists in the doses given with response blunted more by nonselective β-blockers than selective β-blockers. Use of β-blockers in asthma could possibly be based upon a risk assessment on an individual patient basis.

Moderating Effect of Socioeconomic Status on the Relationship between Health Cognitions and Behaviors

BackgroundThere is an established link between socioeconomic status (SES) and performance of health behaviors with more health protective and fewer health-risking behaviors in higher SES groups.PurposeThis research is novel in testing the moderating effect of SES on the relationship among intention, self-efficacy, and subsequent behavior.MethodsEffects were tested on data from three prospective correlational studies examining smoking initiation in adolescents (N = 826), breastfeeding in primiparous women (N = 202), and physical activity in working adults (N = 509).ResultsDespite examining different behaviors, samples, time intervals, and measures of SES, each study showed significant interactions between intention and SES in predicting behavior. In all three tests, the intention–behavior relationship was attenuated among individuals from lower SES groups. No moderation effects of SES were found for self-efficacy.ConclusionsThe intention–health behavior relationship can be attenuated in lower SES samples. This finding may contribute to our understanding of SES differences in health behaviors.

Evaluating a Web-Based MMR Decision Aid to Support Informed Decision-Making by UK Parents: A Before-and-After Feasibility Study.

Objective: The objective of this feasibility study was to evaluate the acceptability and potential effectiveness of a web-based MMR decision aid in supporting informed decision-making for the MMR vaccine. Design: This was a prospective before-and-after evaluation. Setting: Thirty parents of children eligible for MMR vaccination were recruited from two childcare organizations in a moderately deprived community in a city in the north of England. Method: Parents completed postal questionnaires at recruitment, one week and three months after using the decision aid. Data on the acceptability of the decision aid, informed decision-making outcome measures and vaccine uptake were collected. Telephone interviews were conducted with five parents. Acceptability data were analysed using simple descriptive statistics. Repeated measures ANOVAs were undertaken for analysing the informed decision-making data. Content analysis of the qualitative data was undertaken. Results: Twenty six parents (87 per cent) completed all three study questionnaires. The decision aid was found to be acceptable to parents and was considered useful in supporting their informed decision-making. There was a statistically significant increase in parents’ knowledge over time and statistically significant decrease in decisional conflict for the MMR decision. Most parents (88 per cent) reported vaccinating their child. Conclusions: We cannot extrapolate from our data to infer that the decision aid has changed decision-making outcomes or influenced vaccination uptake. However, findings suggest that it may increase knowledge about MMR and reduce decisional conflict to a level where parents can make an informed decision. A randomized controlled trial is now underway to expand on these findings.

Implementation of the Australian HPV vaccination program for adult women: Qualitative key informant interviews

This study sought to evaluate the early implementation of Australias national HPV vaccination program for adult women aged 18-26 years. We conducted qualitative in-depth interviews with 24 program managers and primary care providers in key roles of implementation across the country. While participants had generally positive beliefs about the vaccine, some questioned the cost-effectiveness for women aged 18-26 years. A short timeframe for implementing a unique and complex program raised particular challenges including ensuring providers and consumers received timely access to information. Media attention helped and hindered implementation. Existing primary care systems and close coordination between players helped overcome these issues. Although challenging, delivery of HPV vaccination to adult women is achievable and the Australian experience provides useful information for countries commencing HPV vaccination programs in this population.