Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment

Critical soft skill competencies that clinical nurse educators consider important to evaluate in nurses

AIM

Guided by Benner's framework, From Novice to Expert, this study aimed to identify (1) critical soft skills to be evaluated in nurses and (2) levels of nursing behaviour indicating achievement of soft skills to provide a framework for developing a soft skills rubric.

BACKGROUND/INTRODUCTION

Nurse shortages are often attributable to high turnover rates among nurses. To improve this situation, healthcare facilities implement transition programmes and continuing education with a primary focus on developing and maintaining nurses' knowledge and performance (hard skills). However, balancing hard and soft skills (beliefs, values and attitudes) is key to nurses' quality of care and ultimately to their retention. Despite the importance of soft skills, their intangible nature creates problems in evaluating nurses' attainment of these skills and in providing constructive feedback to help them set concrete goals for improving their practice.

METHODS

This qualitative descriptive study described critical soft skills in the nursing context. A purposeful sampling strategy was used to enrol 13 clinical nurse educators from multiple hospital units; each had more than 2 years of clinical nurse educator experience and had completed preceptor training. One-to-one interviews with these individuals were audio recorded, transcribed and subjected to direct content analysis using NVivo 12. The study follows the Consolidated criteria for reporting qualitative research (COREQ) guidelines for qualitative studies.

FINDINGS

Five main competencies, comprising 20 subcompetencies, were identified: personal growth, effective interactions, professionalism, teamwork and the caring role. For each subcompetency, four skill levels were delineated using clinical indicators.

CONCLUSION

This study's findings can enhance understanding of clinical nurse educators' perceptions regarding soft skills required of nurses.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The soft skills identified can be incorporated into a rubric to be used by clinical nurse educators to evaluate and guide nurses' professional development and contribute to improving quality of care. No patient or public contribution is required for this study.

Health service providers' views on barriers and drivers to childhood vaccination of FDMN/Rohingya refugees: a qualitative study in Cox's Bazar, Bangladesh

Background

Despite established vaccination programs, vaccine-preventable diseases persist among about 900,000 Forcibly Displaced Myanmar Nationals (FDMN)/Rohingya refugees in the world's largest refugee settlement in Bangladesh. Health service providers (HSPs) play a key role in the delivery of childhood vaccination programs. This study explored their views on individual and context barriers and drivers to childhood vaccination in this setting.

Methods

Informed by the theoretical framework of the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavior change, this qualitative study collected data through eight focus group discussions (FGDs) with community health workers (CHWs) and vaccinators in selected camps with high or low vaccination coverage rates, and through 11 in-depth interviews (IDIs) with key informants working in strategic, management, and administrative roles.

Findings

Barriers and drivers were evident across all COM factors for HSPs and caregivers. Among HSPs, knowledge around vaccination acted both as a barrier and driver, while communication skills and confidence in vaccination served as drivers. Caregivers' lack of awareness of vaccination, concerns and mistrust were described as main barriers. Context barriers included information system deficiencies, family dynamics, HSPs' working conditions, and vaccination site accessibility. Context drivers included effective communication, mobilization, and incentives. Differences between high and low coverage camps in Cox's Bazar included variations in HSPs' knowledge, communication strategies, incentive use, and stakeholder collaboration.

Discussion

For better vaccination coverage in the camps, context-related changes regarding collaboration, health workforce and the use of incentives seem necessary. Caregivers' mistrust toward vaccination needs to be considered under the social and historical background of the Rohingya community, and further addressed with targeted communication and campaigning.

A Novel Approach to Computing Preference Estimates for Different Treatment Pathways: An Application in Oncology

BACKGROUND

Patients with cancer may progress through multiple treatments with differing adverse effect profiles. Moreover, pathways may be fixed or flexible in allowing for escalation or de-escalation of treatment depending on interim outcomes. We sought to develop a methodology capable of estimating preferences for the entirety of a pathway involving a sequence of different treatments.

METHODS

Patients with early breast cancer completed an online discrete choice experiment to assess preferences for eight key early breast cancer attributes. Hierarchical Bayesian modeling was used to calculate attribute-level preference weights. Preference weights for hypothetical pathways were estimated by summing the respective weights for efficacy, flexible or fixed pathway, duration, administration regimen, and adverse event risk, the last two of which were time-adjusted by multiplying each weight by the proportion of time spent on a selected treatment.

RESULTS

Increases in the risk of a serious adverse event were most influential in treatment pathway preferences, followed by increases in efficacy and decreases in overall pathway duration. Patients preferred a flexible pathway versus a fixed pathway. Pathway preference estimates fluctuated in a logically consistent manner. Switching from a flexible to a fixed pathway yielded a significantly lower pathway preference. For this same pathway, when adjuvant treatment was replaced with a treatment with a more favorable toxicity profile and shorter duration, it offset the negative impact of the more toxic neoadjuvant chemotherapy.

CONCLUSIONS

This novel methodology accounts for patient preference throughout a sequence of treatments, allowing for comparison of preferences across complex treatment pathways.

Pandemic Fatigue and Preferences for COVID-19 Public Health and Social Measures in China: Nationwide Discrete Choice Experiment

BACKGROUND

Information on the public's preferences for current public health and social measures (PHSMs) and people's mental health under PHSMs is insufficient.

OBJECTIVE

This study aimed to quantify the public's preferences for varied PHSMs and measure the level of pandemic fatigue in the COVID-19 normalization stage in China.

METHODS

A nationwide cross-sectional study with a discrete choice experiment and psychometric scales was conducted to assess public preferences for and attitudes toward PHSMs, using the quota sampling method. The COVID-19 Pandemic Fatigue Scale (CPFS) was used to screen fatigue levels among respondents. The multinomial logit model, latent class model, and Mann-Whitney test were used for statistical analysis. We also conducted subgroup analysis based on sex, age, monthly income, mental health status, and pandemic fatigue status.

RESULTS

A total of 689 respondents across China completed the survey. The discrete choice experiment revealed that respondents attached the greatest importance to the risk of COVID-19 infection within 3 months (45.53%), followed by loss of income within 3 months (30.69%). Vulnerable populations (low-income populations and elderly people) were more sensitive to the risk of infection, while younger respondents were more sensitive to income loss and preferred nonsuspension of social places and transportation. Migrants and those with pandemic fatigue had less acceptance of the mandatory booster vaccination and suspension of transportation. Additionally, a higher pandemic fatigue level was observed in female respondents, younger respondents, migrants, and relatively lower-income respondents (CPFS correlation with age: r=-0.274, P<.001; correlation with monthly income: r=-0.25, P<.001). Mandatory booster COVID-19 vaccination was also not preferred by respondents with a higher level of pandemic fatigue, while universal COVID-19 booster vaccination was preferred by respondents with a lower level of pandemic fatigue.

CONCLUSIONS

Pandemic fatigue is widely prevalent in respondents across China, and respondents desired the resumption of normal social life while being confronted with the fear of COVID-19 infection in the normalization stage of COVID-19 in China. During future pandemics, the mental burden and adherence of residents should be considered for the proper implementation of PHSMs.

Assessing the job preferences of senior medical students for mandatory service: a discrete choice experiment

AIM

To investigate the job preferences of senior medical students for mandatory service as general practitioners using discrete choice experiment.

INTRODUCTION

Health workforce is directly associated with health service coverage and health outcomes. However, there is a global shortage of healthcare workers (HCWs) in rural areas. Discrete choice experiments can guide the policy and decision-makers to increase recruitment and retention of HCWs in remote and rural areas by determining their job preferences. The aim of this study is to investigate job preferences of senior medical students for mandatory service as general practitioners.

METHODS

This cross-sectional survey was conducted among 144 medical students. To estimate students' preferences for different levels of job attributes, a mixed logit model was utilised. Simulations of job uptake rates and willingness to pay (WTP) estimates were computed.

FINDINGS

All attributes had an impact on the job preferences of students with the following order of priority: salary, workload, proximity to family/friends, working environment, facility and developmental status. For a normal workload and a workplace closed to family/friends which were the most valued attributes after salary, WTPs were 2818.8 Turkish lira (TRY) ($398.7) and 2287.5 TRY ($323.6), respectively. The preference weights of various job characteristics were modified by gender, the presence of a HCW parent and willingness to perform mandatory service. To recruit young physicians where they are most needed, monetary incentives appear to be the most efficient intervention. Non-pecuniary job characteristics also affected job preferences. Packages of both monetary and non-monetary incentives tailored to individual characteristics would be the most efficient approach.

How different attributes are weighted in professionals' decision-making in Pediatric Dentistry-a protocol for guiding discrete choice experiment focused on shortening the evidence-based practice implementation for dental care

BACKGROUND

Important evidence has been constantly produced and needs to be converted into practice. Professional consumption of such evidence may be a barrier to its implementation. Then, effective implementation of evidence-based interventions in clinical practice leans on the understanding of how professionals value attributes when choosing between options for dental care, permitting to guide this implementation process by maximizing strengthens and minimizing barriers related to that.

METHODS

This is part of a broader project investigating the potential of incorporating scientific evidence into clinical practice and public policy recommendations and guidelines, identifying strengths and barriers in such an implementation process. The present research protocol comprises a Discrete Choice Experiment (DCE) from the Brazilian oral health professionals' perspective, aiming to assess how different factors are associated with professional decision-making in dental care, including the role of scientific evidence. Different choice sets will be developed, either focusing on understanding the role of scientific evidence in the professional decision-making process or on understanding specific attributes associated with different interventions recently tested in randomized clinical trials and available as newly produced scientific evidence to be used in clinical practice.

DISCUSSION

Translating research into practice usually requires time and effort. Shortening this process may be useful for faster incorporation into clinical practice and beneficial to the population. Understanding the context and professionals' decision-making preferences is crucial to designing more effective implementation and/or educational initiatives. Ultimately, we expect to design an efficient implementation strategy that overcomes threats and potential opportunities identified during the DCEs, creating a customized structure for dental professionals.

TRIAL REGISTRATION

https://osf.io/bhncv .

Research capacity, motivators and barriers to conducting research among healthcare providers in Tanzania's public health system: a mixed methods study

BACKGROUND

Building health research capacity in low- and middle-income countries is essential to achieving universal access to safe, high-quality healthcare. It can enable healthcare workers to conduct locally relevant research and apply findings to strengthen their health delivery systems. However, lack of funding, experience, know-how, and weak research infrastructures hinders their ability. Understanding research capacity, engagement, and contextual factors that either promote or obstruct research efforts by healthcare workers can inform national strategies aimed at building research capacity.

METHODS

We used a convergent mixed-methods study design to understand research capacity and research engagement of healthcare workers in Tanzania's public health system, including the barriers, motivators, and facilitators to conducting research. Our sample included 462 randomly selected healthcare workers from 45 facilities. We conducted surveys and interviews to capture data in five categories: (1) healthcare workers research capacity; (2) research engagement; (3) barriers, motivators, and facilitators; (4) interest in conducting research; and (5) institutional research capacity. We assessed quantitative and qualitative data using frequency and thematic analysis, respectively; we merged the data to identify recurring and unifying concepts.

RESULTS

Respondents reported low experience and confidence in quantitative (34% and 28.7%, respectively) and qualitative research methods (34.5% and 19.6%, respectively). Less than half (44%) of healthcare workers engaged in research. Engagement in research was positively associated with: working at a District Hospital or above (p = 0.006), having a university degree or more (p = 0.007), and previous research experience (p = 0.001); it was negatively associated with female sex (p = 0.033). Barriers to conducting research included lack of research funding, time, skills, opportunities to practice, and research infrastructure. Motivators and facilitators included a desire to address health problems, professional development, and local and international collaborations. Almost all healthcare workers (92%) indicated interest in building their research capacity.

CONCLUSION

Individual and institutional research capacity and engagement among healthcare workers in Tanzania is low, despite high interest for capacity building. We propose a fourfold pathway for building research capacity in Tanzania through (1) high-quality research training and mentorship; (2) strengthening research infrastructure, funding, and coordination; (3) implementing policies and strategies that stimulate engagement; and (4) strengthening local and international collaborations.

Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis

BACKGROUND

It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause.   OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients.  SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification.

SELECTION CRITERIA

We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies.  DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach.  MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes.   AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.

Public Preferences for Policies to Promote COVID-19 Vaccination Uptake: A Discrete Choice Experiment in The Netherlands

OBJECTIVES

The COVID-19 pandemic forms an unprecedented public health, economic, and social crisis. Uptake of vaccination is critical for controlling the pandemic. Nevertheless, vaccination hesitancy is considerable, requiring policies to promote uptake. We investigate Dutch citizens' preferences for policies that aim to promote vaccination through facilitating choice of vaccination, profiling it as the norm, making vaccination more attractive through rewards, or punishing people who reject vaccination.

METHODS

We conducted a discrete choice experiment in which 747 respondents were asked to choose between policies to promote vaccination uptake and their impacts on the number of deaths, people with permanent health problems, households with income loss, and a tax increase.

RESULTS

Respondents generally had a negative preference for policies that promote vaccination. They particularly disliked policies that punish those who reject the vaccine and were more favorable toward policies that reward vaccination, such as awarding additional rights to vaccinated individuals through vaccination passports. Respondents who reject vaccination were in general much more negative about the policy options than respondents who consider accepting the vaccine. Nevertheless, vaccination passports are supported by both respondents who accept the vaccine, those who reject vaccination, and those who are unsure about vaccination.

CONCLUSIONS

This study provides concrete directions for governments attempting to increase the vaccination uptake in ways that are supported by the public. Our results could encourage policy makers to focus on policy options that make vaccination easier and reward people who take the vaccine, as especially the implementation of vaccination passports was supported.

Payments and freedoms: Effects of monetary and legal incentives on COVID-19 vaccination intentions in Germany

Monetary and legal incentives have been proposed to promote COVID-19 vaccination uptake. To evaluate the suitability of incentives, an experiment with German participants examined the effects of payments (varied within subjects: 0 to 10,000 EUR) and freedoms (varied between subjects: vaccination leading vs. not leading to the same benefits as a negative test result) on the vaccination intentions of previously unvaccinated individuals (n = 782) in April 2021. While no effect could be found for freedoms, the share of participants willing to be vaccinated increased with the payment amount. However, a significant change required large rewards of 3,250 EUR or more. While monetary incentives could increase vaccination uptake by a few percentage points, the high costs of implementation challenge the efficiency of the measure and call for alternatives. As the data suggest that considering vaccination as safe, necessary, and prosocial increases an individual's likelihood of wanting to get vaccinated without payment, interventions should focus on these features when promoting vaccination against COVID-19.

Preferences for Delivering Brief Alcohol Intervention to Risky Drinking Parents in Children's Social Care: A Discrete Choice Experiment

AIMS

Many parents in contact with children's social care services misuse alcohol however do not meet the threshold for specialist alcohol treatment, and typically do not receive appropriate support for their needs. Brief alcohol interventions have been found to be effective in healthcare settings, however, it is unknown whether the brief intervention structure delivered within health settings would transfer well into children's social care. This paper aims to examine the characteristics of brief intervention for alcohol misusing parents which social care practitioners consider to be important and acceptable to implement in this sector.

METHODS

We assessed preferences for, and acceptability of, brief alcohol intervention with parents in contact with children's social care using a discrete choice experiment. We recruited 205 children's social care practitioners from London and the North East of England. Data were analysed using mixed logit which accounted for repeated responses.

FINDINGS

Six attributes showed statistically significant coefficients, suggesting that a brief intervention with these attributes would encourage implementation. These were: level of alcohol-related risk targeted; intervention recipient; timing of intervention; duration of sessions; number of sessions and intervention structure. The attribute of most importance identified based on the attribute with the largest coefficient in the conditional logit model was risk level.

CONCLUSIONS

Brief alcohol interventions delivered to parents in social care should focus on the impact upon children and the wider family, they should be a flexible part of on-going casework and should be more intensive and less structured.

Stakeholders' Views on Patient Access Schemes in Malaysia

OBJECTIVES

The healthcare system aspires to ensure improved access to treatment while working within the existing financial constraints and increasing demands. Patient access schemes (PASs) are initiated to improve access. This study seeks the stakeholders' views on the PAS in the public healthcare sector in Malaysia.

METHODS

This is an exploratory qualitative study using a web-based online survey and semistructured interviews. The participants were recruited by purposive sampling, where the Ministry of Health of Malaysia staff, pharmaceutical organization personnel, and patient advocacy organization personnel with experience in PAS were invited to participate. A total of 42 consenting participants answered the survey, whereas the face-to-face interview had 8 participants. Interviews were thematically analyzed using the qualitative data analysis software NVivo V.12. The Medical Research and Ethics Committee, Ministry of Health of Malaysia, approved the study.

RESULTS

Only finance-based PAS was reportedly implemented, and it covered drugs for antineoplastic or immunomodulating therapy, alimentary tract and metabolism, sensory organs, and systemic hormonal preparations. A total of 3 major themes were identified. High upfront cost and high budget impact are a major concern leading to the need for PAS. Identifying the treatment needs was a major concern as well. The readiness of the health system to implement PAS will determine whether the PAS can be successfully implemented. Challenges similar to other jurisdictions were observed in Malaysia, concerns on data availability, the responsibility of the stakeholders, and the need for a legal framework.

CONCLUSION

Most stakeholders responded positively that the PAS would grow. Trust among stakeholders and a structured access plan would enhance the implementation and ensure its success.

Parental preferences for a mandatory vaccination scheme in England: A discrete choice experiment

Background

Mandatory vaccination has been mooted to combat falling childhood vaccine uptake rates in England. This study investigated parental preferences for a mandatory vaccination scheme.

Methods

Discrete choice experiment. Six attributes were investigated: vaccine, child age group, incentive, penalty, ability to opt out, and compensation scheme. Mixed effects conditional logit regression models were used to investigate parental preferences and relative importance of attributes.

Findings

Participants were 1,001 parents of children aged 5 years and under in England (53% female; mean age=33·6 years, SD=7·1; 84% white). Parental preferences were mostly based on incentives (30·7% relative importance; 80·9% [95% confidence interval 76·3–85·0%] preference for parent and 74·8% [71·0–78·3%] for child incentive; reference: no incentive) and penalties (25·4% relative importance; 69·5% [65·7–73·1%] preference for schemes where unvaccinated children cannot attend school or day care and 67·6% [63·6–71·4%] for those withholding financial benefits for parents of unvaccinated children; reference: £450 fine). Parents also preferred schemes that: offered a compensation scheme (18·1% relative importance; 66·4% [62·7–69·8%] preference; reference: not offered), mandated vaccination in children aged 2 years (versus 5 years; 11·4% relative importance; 42·6% [39·4–45·9%] preference; reference: 2 years), mandated the 6-in-1 vaccine (10·5% relative importance; 58·2% [54·6–61·7%] preference; reference: MMR), and that offered only medical exemptions (versus medical and religious belief exemptions; 4·0% relative importance; 45·5% [41·1–50·0%] preference; reference: medical exemptions).

Interpretation

These findings can inform policymakers’ decisions about how best to implement a mandatory childhood vaccination scheme in England.

Funding

Data collection was funded by a British Academy/Leverhulme Small Research Grants (SRG1920\101118).

Diamond goals not graphite! A triangulation approach to clinical teachers' needs assessment

Background: Clinical faculty development plays a significant role in the professional empowerment of future physicians. Identification of educational needs is an important step in planning faculty development. This study identified the educational needs of medical faculties in the clinical setting.

Methods: This cross-sectional needs assessment study was conducted in Iranian medical universities during 2016-2018 using a triangulation paradigm. A total of 384 medical clinical faculties, 54 medical education specialists, and 194 faculty evaluation forms completed by medical residents participated in the study using a convenient randomized sampling method. The data were gleaned with a researcher-made questionnaire with 14 areas developed on the basis of clinical education goals and contexts and were analyzed with SPSS16 using descriptive statistic indices such as mean, standard deviation, and frequency percentile. Analytical tests including independent t-test, chi-square and Cramer's V were also applied (p<0.05). The content validity, face validity, and reliability were approved.

Results: The response rate was %59 (227) for clinical faculties, %77 (42) for medical education specialists, and %58 (110) for residents. Professionalism was the first priority of needs from the viewpoint of clinical faculties and faculty development planners. The clinical teachers' highest level skills, in their own perspective and also students’ perspective, were procedure training and grand round, whereas their lowest level skills were emotional intelligence and morning report. The greatest gap existed between the current skill and the need is management and leadership in the clinical setting. Cramer’s index ranged between 0.18 and 0.34 (p<0.05); hence, there was a correlation between the current status and the announced needs in all subjects.

Conclusion: Designers of faculty development programs ought to pay due attention to areas of professionalism, management, and leadership and carry out accurate and comprehensive planning to enable students to become competent future physicians in the roles of therapist, manager, teacher, supporter, and researcher.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Effectiveness of Mandatory and Incentive-Based Routine Childhood Immunization Programs in Europe: A Systematic Review of the Literature

There is a lack of comprehensive and systematic data and evidence regarding the effectiveness of mandatory and incentive-based vaccination schemes. The results of such programs in some countries have not been adequately studied. A number of countries have recently introduced tightening vaccination measures, and it is important to analyze and assess the results of these programs. The unprecedented situation due to the COVID-19 pandemic and mass vaccination made the topic of the effectiveness of vaccination policies and mandates even more relevant. The aim of the study is to assess childhood vaccination programs implemented in selected countries. The study focuses on initiatives implemented in the European Region of the World Health Organization (WHO). A total of 466 full-text articles were assessed for eligibility, and 26 articles on seven countries were included in the synthesis. Additionally, we obtained and performed an analysis of data on the impact of COVID-19 on vaccine coverage and incidence of vaccine-preventable diseases, and the implementation of vaccine mandates in the selected countries. The evidence collected and analyzed in this review allowed us to conclude that the introduction of children routine vaccination mandates increases vaccine coverage and reduces the incidence of vaccine-preventable diseases when compared to the situation before the introduction of the mandates.

Public acceptability of the UK Soft Drinks Industry Levy: repeat cross-sectional analysis of the International Food Policy Study (2017-2019)

OBJECTIVES

To determine whether public acceptability, in terms of both support for and perceived effectiveness of, the UK Soft Drinks Industry Levy (SDIL) changed between 4 months prior to, and 8 and 20 months after, implementation.

DESIGN

Repeat cross-sectional online survey.

SETTING

The UK.

PARTICIPANTS

UK respondents to the International Food Policy Study aged 18-64 years who provided information on all variables of interest in November-December 2017 (4 months prior to SDIL implementation), 2018 (8 months after) or 2019 (20 months after; n=10 284).

OUTCOME MEASURES

Self-reported support for, and perceived effectiveness of, the SDIL.

RESULTS

The adjusted logistic regression model predicted that 70% (95% CI: 68% to 72%) of participants supported the SDIL in 2017, 68% (95% CI: 67% to 70%) in 2018 and 68% (95% CI: 66% to 70%) in 2019. There was no evidence of a difference in support in 2018 vs 2017 (OR: 0.93; 95% CI: 0.81 to 1.05); or in 2019 vs 2017 (OR: 0.90; 95% CI: 0.78 to 1.03). The adjusted logistic regression model predicted that 72% (95% CI: 70% to 74%) of participants perceived the SDIL to be effective in 2017, 67% (95% CI: 65% to 69%) in 2018 and 67% (95% CI: 64% to 69%) in 2019. There was evidence that perceived effectiveness decreased a small amount in 2018 vs 2017 (OR: 0.78; 95% CI: 0.69 to 0.88). The difference in 2019 vs 2017 was similar.

CONCLUSIONS

We found high support for the SDIL among UK adults and this did not change between 4 months before implementation and 8 or 20 months after. While perceived effectiveness remained high, there was evidence that this decreased slightly after implementation in 2018, but no further in 2019. Greater understanding of influences on public acceptability of effective structural public health interventions is required.

Vaccine preferences driving vaccine-decision making of different target groups: a systematic review of choice-based experiments

BACKGROUND

Choice-based experiments have been increasingly used to elicit preferences for vaccines and vaccination programs. This study aims to systematically identify and examine choice-based experiments assessing (differences in) vaccine preferences of vaccinees, representatives and health advisors.

METHODS

Five electronic databases were searched on choice-based conjoint analysis studies or discrete choice experiments capturing vaccine preferences of children, adolescents, parents, adults and healthcare professionals for attributes of vaccines or vaccine settings up to September 2020. Data was extracted using a standardized form covering all important aspects of choice experiments. A quality assessment was used to assess the validity of studies. Attributes were categorized into outcome, process, cost and other. The importance of attributes was assessed by the frequency of reporting and statistical significance. Results were compared between high-quality studies and lower-quality studies.

RESULTS

A total of 42 studies were included, with the majority conducted in high-income countries after 2010 (resp. n = 34 and n = 37). Preferences of representatives were studied in nearly half of the studies (47.6%), followed by vaccinees (35.7%) and health advisors (9.5%). Sixteen high-quality studies passed the quality assessment. Outcome- and cost- related attributes such as vaccine effectiveness, vaccine risk, cost and protection duration were most often statistically significant across both target groups, with vaccine effectiveness being the most important. Risks associated with vaccination, such as side effects, were more often statistically significant in studies targeting vaccinees, while cost-related attributes were more often statistically significant in studies of representatives. Process-related attributes such as vaccine accessibility and time were least important across both target groups.

CONCLUSION

To our knowledge, this is the first systematic review in which vaccine preferences of different target groups were assessed and compared. The same attributes were most important for vaccine decisions of vaccinees and representatives, with only minor differences in level of evidence for vaccine risk and cost. Future research on vaccine preferences of health advisors and/or among target groups in low-resource settings would give insight into the generalizability of current findings.

Barriers to preventive care utilization among Hong Kong community-dwelling older people and their views on using financial incentives to improve preventive care utilization

BACKGROUND

Financial incentive is increasingly used as a mean to promote preventive care utilization (PCU), but the current Elderly Health Care Voucher Scheme (EHCVS) in Hong Kong is ineffective for encouraging PCU.

OBJECTIVE

To explore the older people's barriers to PCU and their views on financial incentive, including EHCVS, for improving private PCU.

DESIGN AND SETTING

Focus-group discussions were conducted in community elderly centres located in five districts of Hong Kong.

PARTICIPANTS

Community-dwelling older people aged 60 years or above.

RESULTS

Lack of understanding about preventive care and low awareness of the need for preventive care were key factors for the low motivation for PCU. Uncertainty over the level of service fee charged and concerns over service quality hindered the choice of using the private service providers under the current EHCVS. Financial incentives specific for preventive care services were thought to be cues to actions and guides for service promotion. However, some flexibility in service coverage and a set time limit of the financial incentives were preferred to accommodate individual needs.

CONCLUSIONS

Apart from promoting knowledge of preventive care, official monitoring for service fee and quality is important for empowering older people to choose private service providers for preventive care. Financial incentives for preventive care services should be more specific to cue service promotion and uptake of preventive care while maintaining flexibility to accommodate individual needs.

PATIENT OR PUBLIC CONTRIBUTION

Participants were recruited using purposive sampling with the coordination of community elderly centres. Data were analysed using thematic coding.

Parental attitudes towards mandatory vaccination; a systematic review

Uptake of childhood vaccines is decreasing. While mandatory vaccination schemes can increase vaccine uptake rates, they can also cause backlash among some parents. We conducted a systematic review investigating parental beliefs about vaccine mandates and factors associated with support for mandatory vaccination schemes. We searched Embase, Ovid MEDLINE, Global Health, APA PsycINFO and Web of Science from inception to 17th September 2020. Seventeen studies (five qualitative, twelve quantitative) were eligible for inclusion. We synthesised results of qualitative and quantitative studies separately. As quantitative studies were heterogeneous in the mandatory vaccination schemes and associated factors investigated, there was no scope to conduct a meta-analysis. Instead, data were narratively synthesised, considering risk of bias ratings. Qualitative data were synthesised using meta-ethnography, synthesising themes reported across studies included. Quantitative studies reported that support for mandatory vaccination schemes was reasonably high (73% to 88%). However, due to heterogeneity, there was little evidence for any factors being consistently associated with support for mandatory vaccination. Qualitative studies gave an insight into how parents perceive mandatory vaccination. Studies found that parents perceived mandatory vaccination schemes as an infringement of their rights, and particularly disliked schemes offering financial incentives for vaccination. Nevertheless, some parents felt that schemes limiting access to schooling of unvaccinated children gave them "peace of mind." Results should be taken with caution due to the purposive use of non-representative samples. Before deciding to mandate vaccination, it is important to understand the impact it could have on parental beliefs and attitudes about vaccination.

Maximizing Participant Engagement, Participation, and Retention in Cohort Studies Using Digital Methods: Rapid Review to Inform the Next Generation of Very Large Birth Cohorts

BACKGROUND

Many current research needs can only be addressed using very large cohorts. In such studies, traditional one-on-one phone, face-to-face, or paper-based engagement may not be feasible. The only realistic mechanism for maintaining engagement and participation at this scale is via digital methods. Given the substantial investment being made into very large birth cohort studies, evidence for optimal methods of participant engagement, participation, and retention over sustained periods without in-person contact from researchers is paramount.

OBJECTIVE

This study aims to provide an overview of systematic reviews and meta-analyses evaluating alternative strategies for maximizing participant engagement and retention rates in large-scale studies using digital methods.

METHODS

We used a rapid review method by searching PubMed and Ovid MEDLINE databases from January 2012 to December 2019. Studies evaluating at least 1 e-engagement, participation, or retention strategy were eligible. Articles were screened for relevance based on preset inclusion and exclusion criteria. The methodological quality of the included reviews was assessed using the AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews 2) measurement tool, and a narrative synthesis of the data was conducted.

RESULTS

The literature search yielded 19 eligible reviews. Overall, 63% (n=12) of these reviews reported on the effectiveness of e-engagement or participation promotion strategies. These evaluations were generally not conducted within very large observational digital cohorts. Most of the contributing reviews included multipurpose cohort studies (with both observational and interventional elements) conducted in clinical and research settings. Email or SMS text message reminders, SMS text messages or voice notifications, and incentives were the most commonly used design features to engage and retain participants. For parental outcomes, engagement-facilitation interventions influenced uptake and behavior change, including video feedback, goal setting, and intensive human facilitation and support. Participant-stated preferences for content included new knowledge, reminders, solutions, and suggestions about health issues presented in a clear, short, and personalized way. Perinatal and postpartum women valued self-monitoring and personalized feedback. Digital reminders and multiple SMS text messages were specific strategies that were found to increase adherence to medication and clinic attendance, respectively.

CONCLUSIONS

This review adds to the growing literature evaluating methods to optimize engagement and participation that may apply to large-scale studies using digital methods; it is promising that most e-engagement and participation promotion strategies appear to be effective. However, these reviews canvassed relatively few strategies, suggesting that few alternative strategies have been experimentally evaluated. The reviews also revealed a dearth of experimental evidence generated within very large observational digital cohort studies, which may reflect the small number of such studies worldwide. Thus, very large studies may need to proactively build in experimental opportunities to test engagement and retention approaches to enhance the success of their own and other large digital contact studies.

Perceived Challenges and Online Harms from Social Media Use on a Severity Continuum: A Qualitative Psychological Stakeholder Perspective

Evidence suggests that problematic use of gaming, the internet, and social media among adolescents is on the rise, affecting multiple psycho-emotional domains. However, research providing a comprehensive and triangulated stakeholder perspective of perceived harms is lacking. How are adolescent online harms experienced and conceptualized by students, parents, and teachers? The present study comprised part of a qualitative needs assessment investigation with the use of focus groups and individual interviews among key stakeholder groups assessing perceived impacts with a focus on the negative consequences and perceived harms. The study’s sample consisted of students (N = 42, M_age = 13.5, SD = 2.3), parents (N = 9, M_age = 37, SD = 5.6) and teachers (N = 9, M_age = 34, SD = 4.9) from the UK. Data were analysed with thematic analysis. Findings focused primarily on social media use impacts and indicated that processes underlying impacts experienced by adolescents may be conceptualized on a severity continuum. Stakeholder consensus on perceptions of challenges and perceived harms formed the second theme, with impacts further analysed as relating to time displacement, peer judgement, sensory overload and context of the adolescent with functional (performance, task switching, use of multiple devices), cognitive (loss or deterioration of attentional focus, attention deficit), and emotional consequences (stress, anxiety, obsessive-compulsive/checking behaviours). A third theme formed was individual vulnerabilities predisposing poor mental health outcomes. The final theme related to impacts dependent on context and meaning attached. Findings suggest a consideration of a spectrum approach encompassing a broader range of potential psychological challenges and perceived harms beyond safety concerns and addiction in understanding problematic adolescent online experiences. Understanding perceived harms can aid the objective setting of interventions and consideration of mental health literacy in school curricula.

Vaccination concerns, beliefs and practices among Ukrainian migrants in Poland: a qualitative study

BACKGROUND

Ukrainians numbering approximately 1.2 million are the largest migrant group in Poland. Data on vaccination coverage among migrants are not collected in EU, including Poland. Therefore, this qualitative study aimed to identify vaccination practices in this migrant group, to explore facilitators and barriers to vaccination and related access to Polish healthcare services.

METHODS

In September 2019, a qualitative study of Ukrainian migrants (UMs) living in Szczecin, Poland, and recruited through a snowball sampling method, was conducted. Using a semi-structured topic guide, four focus groups were held with 22 UMs aged 18-45. Participants were asked about their attitudes towards vaccination in general with comparison between services in Poland and Ukraine. Following transcription and translation, a thematic analysis was conducted.

RESULTS

Respondents were distrustful of Ukrainian vaccination policy, medical personnel and individual vaccines, however, they often returned to Ukraine for dental and gynaecological appoint-ments. While critical with regards to registering with Polish GPs practices, UMs were confident in health professionals, as well as vaccine delivery. Vaccines were perceived as safer and of better quality than in Ukraine. Difficulties in translating vaccination records were rarely reported, verbal communi-cation was not problematic due to language similarities. All UM parents reported vaccinating their children according to the Polish schedule. However, a significant number of adult UMs have not completed mandatory vaccinations, although they may have obtained false immunization certificates; according to UMs those can be obtained by bribing. Participants reported lower acceptance of the influenza vaccine, mainly due to perceptions around its importance; none had been vaccinated against influenza. None of UMs had heard of the HPV vaccine. UMs experienced challenges in accessing credible online vaccination information in Ukrainian, no official local health authority vaccination material existed either, except for information about measles.

CONCLUSIONS

This study pinpointed positive UM attitudes and practices regarding child vaccination in the Polish healthcare system and identified issues for improvement, such as adult vaccination. Health communication should be more tailored within UMs information delivery systems to enable migrants to make informed choices about vaccination. Further research is needed to better assess factors affecting vaccine uptake identified in this study.

A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa

BACKGROUND

The uptake and adherence of daily oral PrEP has been poor in high-risk populations in South Africa including young people. We used qualitative research methods to explore user preferences for daily and on-demand oral PrEP use among young South Africans, and to inform the identification of critical attributes and attribute-levels for quantitative analysis of user preferences, i.e. a discrete choice experiment (DCE).

METHODS

Data were collected between September and November 2018 from eight group discussions and 20 in-depth interviews with young people 13 to 24 years in Cape Town and Johannesburg. Using a convenience sampling strategy, participants were stratified by sex and age. Interviewers used a semi-structured interview guide to discuss several attributes (dosing regimen, location, costs, side effects, and protection period) for PrEP access and use. Group discussions and in-depth interviews were audio-recorded, transcribed verbatim and translated to English. We used framework analysis to explore context-specific attributes and attribute-levels for delivering oral PrEP in South Africa. The adolescent community advisory board, expert and study team opinions were consulted for the final DCE attributes and levels.

RESULTS

We enrolled 74 participants who were 51% (n = 38/74) male, had a median age of 18.5 [Interquartile range = 16-21.25] years, 91% (n = 67/74) identified as heterosexual and 49% (n = 36/74) had not completed 12th grade education. Using the qualitative data, we identified five candidate attributes including (1) dosing regimen, (2) location to get PrEP, (3) cost, (4) route of administration and (5) frequency. After discussions with experts and the study team, we revised the DCE to include the following five attributes and levels: dosing regime: daily, and on-demand PrEP; location: private pharmacy, public clinic, mobile clinic, ATM); cost: free-of-charge, R50 (~2GBP), R265 (~12GBP); side effects: nausea, headache, rash; and duration of protection: fulltime protection versus when PrEP is used).

CONCLUSIONS

There is limited literature on qualitative research methods describing the step-by-step process of developing a DCE for PrEP in adolescents, especially in resource-constrained countries. We provide the process followed for the DCE technique to understand user preferences for daily and on-demand oral PrEP among young people in South Africa.

Decision making processes underlying avoidance of mandatory child vaccination in Croatia - a qualitative study

Despite extensive research evidencing child vaccination is safe and effective, we are witnessing a trend of increasing vaccine hesitancy which is listed among the top ten global health threats. Although some countries incorporate mandatory vaccination programs, no particularly efficient strategies for addressing vaccine avoidance have so far been identified. Within this study we investigated perceptions and reasoning of vaccine hesitant parents from Croatia where child vaccination is mandatory. The aims were to reveal different strategies by which they avoid mandatory vaccination schedules and hypothetical situations in which they would reconsider vaccinating, as well as to identify features of related decision-making. We conducted 25 semi-structured interviews with vaccine hesitant parents and analyzed the data using the framework of thematic analyses. The identified themes were related to the parents’ decision-making process, reflection as well as justification of their decision, avoidance behavior of mandatory vaccination schedules and related consequences, dealing with outcomes of the decision and reconsidering vaccinating. The results support and extend previous findings regarding vaccine reasoning, linking hesitancy with the experientially intuitive thinking style and social intuitionist model of moral reasoning. The findings provide important insights into vaccination avoidance and potential for reconsideration, as well as dealing with related risks. Furthermore, we offer a general framework as well as practical guidelines that may help the development of strategies aimed at increasing vaccination rates.

A qualitative exploration of using financial incentives to improve vaccination uptake via consent form return in female adolescents in London

OBJECTIVES

Incentivising vaccine consent form return may improve vaccine uptake and be seen as less coercive than incentivising vaccination itself. We assessed the acceptability of financial incentives in this context among adolescent females and explored potential mechanisms by which incentives might change behaviour.

DESIGN

Focus groups and analysis of free-text questionnaire responses.

METHODS

Study 1: 36 female secondary students in London (age 13-14) participated in six focus groups exploring the use of incentives in the context of vaccination. Data were analysed thematically. Study 2: was conducted to triangulate the findings of Study 1, by analysing free-text questionnaire responses from 181 female secondary students in London (age 12-13) reporting their opinion of incentivising consent form return. Data from Study 1 was also used to explore perceived potential mechanisms of action by which incentives might encourage consent form return.

RESULTS

Focus group participants had positive attitudes towards incentives, with 61% of free-text responses also expressing this. Most focus group participants thought that incentives would encourage consent form return (18% of free-text respondents spontaneously also mentioned this). While incentivising consent form return was seen as ethical, focus group participants who incorrectly thought that vaccine receipt was being incentivised raised concerns about bribery, although only 4% of free text respondents reported these concerns. Frequently raised mechanisms of action included incentives increasing engagement with, and the perceived value of consent form return.

CONCLUSIONS

Adolescents had positive views of financially incentivising consent form return to promote vaccine uptake, although care must be taken to reduce misconceptions regarding what is being incentivised. Incentivising vaccination was seen as coercive, but incentivising actions that increase the likelihood of vaccination (i.e. consent form return) were not. Incentives may encourage adolescents to return consent forms by helping them engage with this behaviour or increasing its' perceived value.

Utilising Patient and Public Involvement in Stated Preference Research in Health: Learning from the Existing Literature and a Case Study

Publications reporting discrete choice experiments of healthcare interventions rarely discuss whether patient and public involvement (PPI) activities have been conducted. This paper presents examples from the existing literature and a detailed case study from the National Institute for Health Research-funded PATHWAY programme that comprehensively included PPI activities at multiple stages of preference research. Reflecting on these examples, as well as the wider PPI literature, we describe the different stages at which it is possible to effectively incorporate PPI across preference research, including the design, recruitment and dissemination of projects. Benefits of PPI activities include gaining practical insights from a wider perspective, which can positively impact experiment design as well as survey materials. Further benefits included advice around recruitment and reaching a greater audience with dissemination activities, amongst others. There are challenges associated with PPI activities; examples include time, cost and outlining expectations. Overall, although we acknowledge practical difficulties associated with PPI, this work highlights that it is possible for preference researchers to implement PPI across preference research. Further research systematically comparing methods related to PPI in preference research and their associated impact on the methods and results of studies would strengthen the literature.

The Role of Recreational Online Activities in School-Based Screen Time Sedentary Behaviour Interventions for Adolescents: A Systematic and Critical Literature Review

Sedentary behaviours are highly associated with obesity and other important health outcomes in adolescence. This paper reviews screen time and its role within school-based behavioural interventions targeting adolescents between the years 2007 and 2019. A systematic literature review following PRISMA guidelines was conducted across five major databases to identify interventions targeting screen time—in addition to TV/DVD viewing. The review identified a total of 30 papers analysing 15 studies across 16 countries aiming at addressing reduction of recreational screen time (internet use and gaming) in addition to television/DVD viewing. All of the interventions focused exclusively on behaviour change, targeting in the majority both reduction of sedentary behaviours along with strategies to increase physical activity levels. A mix of intervention effects were found in the reviewed studies. Findings suggest aiming only for reduction in time spent on screen-based behaviour within interventions could be a limited strategy in ameliorating excessive screen use, if not targeted, in parallel, with strategies to address other developmental, contextual and motivational factors that are key components in driving the occurrence and maintenance of adolescent online behaviours. Additionally, it raises the need for a differential treatment and assessment of each online activity within the interventions due to the heterogeneity of the construct of screen time. Recommendations for enhancing the effectiveness of school-based sedentary behaviour interventions and implications for public policy are discussed.

Willingness-to-pay for long-lasting insecticide-treated bed nets: a discrete choice experiment with real payment in Ghana

Background

Expanding access to long-lasting insecticidal nets (LLINs) is difficult if one is limited to government and donor financial resources. Private commercial markets could play a larger role in the continuous distribution of LLINs by offering differentiated LLINs to middle-class Ghanaians. This population segment has disposable income and may be willing to pay for LLINs that meet their preferences. Measuring the willingness-to-pay (WTP) for LLINs with specialty features that appeal to middle-class Ghanaians could help malaria control programmes understand what is the potential for private markets to work alongside fully subsidized LLIN distribution channels to assist in spreading this commodity.

Methods

This study conducted a discrete choice experiment (DCE) including a real payment choice among a representative sample of 628 middle-income households living in Ashanti, Greater Accra, and Western regions in Ghana. The DCE presented 18 paired combinations of LLIN features and various prices. Respondents indicated which LLIN of each pair they preferred and whether they would purchase it. To validate stated willingness-to-pay, each participant was given a cash payment of $14.30 (GHS 65) that they could either keep or immediately spend on one of the LLIN products.

Results

The households’ average probability of purchasing a LLIN with specialty features was 43.8% (S.D. 0.07) and WTP was $7.48 (GHS34.0). The preferred LLIN features were conical or rectangular one-point-hang shape, queen size, and zipper entry. The average WTP for a LLIN with all the preferred features was $18.48 (GHS 84). In a scenario with the private LLIN market, the public sector outlay could be reduced by 39% and private LLIN sales would generate $8.1 million ($311 per every 100 households) in revenue in the study area that would support jobs for Ghanaian retailers, distributors, and importers of LLINs.

Conclusion

Results support a scenario in which commercial markets for LLINs could play a significant role in improving access to LLINs for middle-income Ghanaians. Manufacturers interested could offer LLIN designs with features that are most highly valued among middle-income households in Ghana and maintain a retail price that could yield sufficient economic returns.

The Relationship between Self-Reported Exposure to Sugar-Sweetened Beverage Promotions and Intake: Cross-Sectional Analysis of the 2017 International Food Policy Study

Sugar-sweetened beverage (SSB) consumption is independently associated with several non-communicable diseases, so policymakers are increasingly implementing measures, such as marketing regulation, to reduce intake. To help understand how such measures work, this study examined the association between SSB consumption and self-reported exposure to SSB promotions, both overall and by type of promotion, and whether these relationships vary between the UK, USA, Canada, Mexico, and Australia. Cross-sectional analysis of the online 2017 International Food Policy Study was performed (n = 15,515). Participants were grouped into 5265 (34%) non-, 5117 (33%) low-, and 5133 (33%) high-SSB consumers. Multinomial logistic regression models examined whether SSB consumption varied by exposure to total SSB promotion and by type: traditional, digital, recreational environment, and functional environment. Multiplicative interactions were included to investigate international variations. An additional unit of total self-reported SSB promotion exposure increased the likelihood of participants being low SSB consumers (relative risk ratio (RRR) = 1.08, 95% confidence interval (CI) = 1.06–1.10) and high SSB consumers (RRR = 1.13, 95% CI = 1.11–1.16). Only exposure to traditional and digital promotion increased the likelihood of participants being SSB consumers, though this may be explained by degree of exposure, which was not measured in this study. Some evidence illustrated international variation in these relationships.

Assessing the methodological quality of systematic reviews of interventions aimed at improving vaccination coverage using AMSTAR and ROBIS checklists

Introduction: Systematic reviews (SRs) are the backbone of evidence-based health care, but no gold standard exists to assess their methodological quality. Although the AMSTAR tool is accepted for analyzing the quality of SRs, the ROBIS instrument was recently developed. This study compared the capacity of both instruments to capture the quality of SRs of interventions for improving vaccination coverage.Methods: We conducted a comprehensive literature search in the Cochrane Library and PubMed. Two reviewers independently screened the search output, assessed study eligibility, and extracted data from eligible SRs; resolving differences through consensus. We conducted Principal Component Analysis (PCA) in Stata 14 to determine similarities and differences between AMSTAR and ROBIS.Results: A total of 2322 records were identified through the search and 75 full-text publications were assessed for eligibility, of which 57 met inclusion criteria. Using AMSTAR, we found 32%, 60% and 9% of SRs to have high, moderate and low quality, respectively. With ROBIS, we judged 74%, 14% and 12% of SRs to have low, unclear and high risk of bias. PCA showed that SRs with low risk of bias in ROBIS clustered together with SRs having high-quality in AMSTAR, and SRs with high risk of bias in ROBIS clustered with low-quality SRs in AMSTAR.Conclusions: Our findings suggest that there is an association between methodological quality and risk of bias in SRs of interventions focused on improving vaccination coverage. Therefore, either AMSTAR or ROBIS checklists can be used to evaluate methodological quality of SRs in vaccinology.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

Do health professionals value genomic testing? A discrete choice experiment in inherited cardiovascular disease

Next generation sequencing (NGS) approaches are moving from research into clinical practice. However, the optimal NGS approach in well-defined adult-onset familial diseases, such as inherited cardiovascular disease, remains unclear. We aimed to determine which attributes encouraged or discouraged the uptake of genomic tests in this context, and whether this differed by test type. We conducted a web-based discrete choice experiment in health professionals in the UK who order NGS tests for inherited cardiovascular disease. Respondents completed 12 hypothetical choice tasks in which they selected a preferred test from four alternatives: whole genome sequencing, whole exome sequencing, panel testing and genetic testing not indicated. Tests were specified in terms of five attributes: diagnostic yield, detection rate for variants of unknown significance, cost, quantity of counselling received and disclosure of secondary findings. Mixed logit regression analysis was used to analyse the choice data. We found that uptake of NGS increases if tests identify more pathogenic mutations, identify fewer variants of unknown significance, or cost less. Respondents were willing to pay £117 for every 1% increase in diagnostic yield. Considerable heterogeneity was observed around preferences for several test attributes. Overall, panel testing had the highest predicted uptake rate. Our results indicate that NGS tests are valued by health professionals for well-defined adult-onset familial diseases, however, these professionals have strong preferences for panel testing rather than whole genome sequencing and whole exome sequencing. This finding suggests that different uptake rates should be explicitly modelled when designing and evaluating future genomic testing services.

Parental Perspectives on Financial Incentives for Adolescents: Findings From Qualitative Interviews

Background. Financial incentives are becoming more common to promote health behaviors; however, little is known about the acceptability of incentivizing adolescent health behaviors. Design. Qualitative semistructured phone interviews were conducted with 26 parents who had participated in a research study involving incentivizing a recommended, preventive adolescent health behavior (human papillomavirus vaccination). Data were coded and analyzed to identify themes. Interview domains included the following: preferred incentive distribution, ideal financial incentive amount, and general reactions to economic incentives for preventative services. Results. Parents held positive perceptions about incentives and most parents felt that the incentive could be provided directly to their adolescent child, rather than to the parent. Parents stated several benefits from incentivizing adolescent health behavior including creating an opportunity to teach their child about money, reimbursing families for time and effort, and motivating the adolescent to complete the health behavior. Topics for consideration when providing cash incentives to adolescents included the adolescent's maturity level, parents' desire to monitor adolescent's spending, and parents' want to remain involved in health care and financial decisions for their adolescent. Conclusions. This study demonstrates the potential for parental acceptance of financial incentives for adolescent health behaviors and explores areas of parental concern around financial incentives, which could help inform future health care-based incentive programs.

Not quite a doctor, but should I help? A qualitative exploration of medical students' attitudes towards responding to medical emergencies that occur in the public domain

OBJECTIVE

To explore medical students' views on and experiences of responding to out-of-hospital medical emergencies.

SETTING

University College London (UCL).

PARTICIPANTS

11 UCL Medical School students.

STUDY DESIGN

Qualitative.

METHODS AND OUTCOME MEASURES

We carried out 11 one-to-one semistructured interviews, with participant validation and reflective work. The data were analysed using thematic analysis.

RESULTS

Three core themes were identified. (1) 'We Did Debate a Bit: Should We Go? Should We Not?'-Students' decisions to respond were based on the appearance of the casualty; the presence and actions of bystanders; witnessing the incident; self-perceived competence, confidence and knowledge; and personal experiences and feelings associated with medical emergencies. (2) 'It Would Represent the Medical Profession Well if We Did Step In and Help'-Students felt that they had an ethical and/or professional duty to help. (3) 'No One Should Die Because of a Lack of… Basic Life-Saving Techniques'-Students felt that medical school training alone had not sufficiently prepared them to respond to out-of-hospital medical emergencies. Improvements to training were suggested: integrating first aid/response training into the horizontal (systems-based) modules; teaching both common and less common medical emergencies and presentations; training that is led by experienced first responders and that increases students' exposure to out-of-hospital medical emergencies; and providing more revision training sessions.

CONCLUSIONS

Students felt that medical school training could be improved to better prepare them for responding to out-of-hospital medical emergencies, and wanted clarification on whether or not they have an ethical and/or professional duty to help. Further mixed-methods research using a larger sample needs to be carried out to confirm whether findings are transferable to other UK medical schools.

Support for, and perceived effectiveness of, the UK soft drinks industry levy among UK adults: cross-sectional analysis of the International Food Policy Study

OBJECTIVES

To answer four questions: What are attitudes, knowledge and social norms around sugar-sweetened beverages (SSBs)? What are current levels of trust in messages on SSBs? What is current support for, and perceived effectiveness of, the UK soft drinks industry levy (SDIL)? What is the association between attitudes, knowledge, social norms, trust, SSB consumption and sociodemographic factors; and support for, and perceived effectiveness of, the SDIL?

DESIGN

Cross-sectional online survey.

SETTING

UK.

PARTICIPANTS

UK respondents to the 2017 International Food Policy Study aged 18-64 years who provided information on all variables of interest (n=3104).

OUTCOME MEASURES

Self-reported perceived effectiveness of, and support for, the SDIL.

RESULTS

Most participants supported the SDIL (70%), believed it would be effective (71%), had a positive attitude to SSBs (62%), had knowledge of the link between SSBs and obesity (90%), and trusted messages from health experts (61%), but not those from the food and beverage industry (73%). Nearly half (46%) had negative social norms about drinking SSBs. In adjusted models, older age, non-consumption of SSBs, social norms to not drinks SSBs, knowledge of the link between SSBs and obesity and trust in health expert messages were associated with greater support for the SDIL, whereas having dependent children and trusting messages from the food and beverage industry were associated with less support. In adjusted models, older age was associated with lower perceived effectiveness of the SDIL, whereas social norms to not drink SSBs, negative attitudes to SSBs and trusting messages from health experts and the food and beverage industry were associated with greater perceived effectiveness.

CONCLUSIONS

There was strong support for the SDIL and belief that it would be effective. Those with more 'public health' orientated norms and trust were generally more likely to support the SDIL or believe that it would be effective.

Vaccination in England: a review of why business as usual is not enough to maintain coverage

BACKGROUND

The vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.

METHODS

We undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.

RESULTS

We analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.

CONCLUSIONS

The evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.

Individual Preferences for Child and Adolescent Vaccine Attributes: A Systematic Review of the Stated Preference Literature

BACKGROUND

Discrete choice experiments are increasingly used to assess preferences for vaccines and vaccine service delivery.

OBJECTIVES

To synthesize and critically assess the application of discrete choice experiments in childhood/adolescent vaccines, to describe how discrete choice experiments have been applied to understand preferences, and to evaluate the use of discrete choice experiment data to inform estimates of vaccine uptake.

METHODS

We conducted a systematic review of six electronic databases. Included studies were discrete choice experiments and conjoint analyses published from 2000 to 2016 related to childhood/adolescent vaccines where respondents were parents, children/adolescents, or service providers. Validity assessment was used to assess study quality and risk of bias.

RESULTS

In total, 27 articles were included, representing 21 different studies. A majority of articles were published between 2011 and 2016. Vaccines studied included human papillomavirus (24%), influenza (19%), meningococcal vaccines (14%), childhood vaccines (14%), hypothetical vaccines (10%), hepatitis B (5%), and diphtheria, tetanus, pertussis, hepatitis B, poliomyelitis, and Haemophilus influenzae type b (5%). Most studies assessed parent preferences (67%). The most common attributes were risk (24%), degree/duration of protection (21%), and cost (15%). Commonly reported outcome measures were estimates of uptake (33%), willingness-to-pay (22%), and other marginal rates of substitution (14%). Validity assessments yielded high scores overall. Areas of weakness included low response rates, inefficient experimental design, and failure to conduct formative qualitative work and a pilot of the discrete choice experiment.

CONCLUSION

This is the first systematic review of childhood/adolescent vaccine-related discrete choice experiments. In future, special attention should be paid to ensuring that choice context and discrete choice experiment design are compatible to generate reliable estimates of uptake.

Women's preferences for alternative financial incentive schemes for breastfeeding: A discrete choice experiment

Background

Increasing breastfeeding rates have been associated with reductions in disease in babies and mothers as well as in related costs. ‘Nourishing Start for Health (NoSH)’, a financial incentive scheme has been proposed as a potentially effective way to increase both the number of mothers breastfeeding and duration of breastfeeding.

Aims

To establish women’s relative preferences for different aspects of a financial incentive scheme for breastfeeding and to identify importance of scheme characteristics on probability on participation in an incentive scheme.

Methods

A discrete choice experiment (DCE) obtained information on alternative specifications of the NoSH scheme designed to promote continued breastfeeding duration until at least 6 weeks after birth. Four attributes framed alternative scheme designs: value of the incentive; minimum breastfeeding duration required to receive incentive; method of verifying breastfeeding; type of incentive. Three versions of the DCE questionnaire, each containing 8 different choice sets, provided 24 choice sets for analysis. The questionnaire was mailed to 2,531 women in the South Yorkshire Cohort (SYC) aged 16–45 years in IMD quintiles 3–5. The analytic approach considered conditional and mixed effects logistic models to account for preference heterogeneity that may be associated with a variation in effects mediated by respondents’ characteristics.

Results

564 women completed the questionnaire and a response rate of 22% was achieved. Most of the included attributes were found to affect utility and therefore the probability to participate in the incentive scheme. Higher rewards were preferred, although the type of incentive significantly affected women’s preferences on average. We found evidence for preference heterogeneity based on individual characteristics that mediated preferences for an incentive scheme.Conclusions

Although participants’ opinion in our sample was mixed, financial incentives for breastfeeding may be an acceptable and effective instrument to change behaviour. However, individual characteristics could mediate the effect and should therefore be considered when developing and targeting future interventions.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Assessing the acceptability of incentivising HPV vaccination consent form return as a means of increasing uptake

BACKGROUND

Uptake of human papillomavirus (HPV) vaccination is high overall but there are disparities in uptake, particularly by ethnicity. Incentivising vaccination consent form return is a promising approach to increase vaccination uptake. As part of a randomised feasibility trial we qualitatively assessed the acceptability of increasing uptake of HPV vaccination by incentivising consent form return.

METHODS

In the context of a two-arm, cluster randomised feasibility trial, qualitative free-text questionnaire responses were collected from adolescent girls (n = 181) and their parents (n = 61), assessing the acceptability of an incentive intervention to increase HPV vaccination consent form return. In the incentive intervention arm, girls who returned a signed consent form (regardless of whether consent was given or refused), had a 1-in-10 chance of winning a £50 shopping voucher. Telephone interviews were also conducted with members of staff from participating schools (n = 6), assessing the acceptability of the incentive. Data were analysed thematically.

RESULTS

Girls and parents provided a mix of positive, negative and ambivalent responses about the use of the incentive to encourage HPV vaccination consent form return. Both girls and parents held misconceptions about the nature of the incentive, wrongly believing that the incentive was dependent on vaccination receipt rather than consent form return. School staff members also expressed a mix of opinions on the acceptability of the incentive, including perceptions of effectiveness and ethics.

CONCLUSIONS

The use of an incentive intervention to encourage the return of HPV vaccination consent forms was found to be moderately acceptable to those receiving and delivering the intervention, although a number of changes are required to improve this. In particular, improving communication about the nature of the incentive to reduce misconceptions is vital. These findings suggest that incentivising consent form return may be an acceptable means of improving HPV vaccination rates, should improvements be made.

TRIAL REGISTRATION

ISRCTN Registry; ISRCTN72136061 , 26 September 2016, retrospectively registered.

A pragmatic multicentre randomised controlled trial comparing stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease: the eTHoS study

BACKGROUND

Haemorrhoids are a benign anorectal condition and are highly prevalent in the UK population. Treatments involve clinic-based procedures and surgery. The surgical procedures available include stapled haemorrhoidopexy (SH) and traditional haemorrhoidectomy (TH), and over 25,000 operations are performed for haemorrhoids annually in the UK. The disease is therefore important both to patients and to health service commissioners. Debate remains as to which of these surgical procedures is the most clinically effective and cost-effective.

OBJECTIVE

The aim of this study was to compare the clinical effectiveness and cost-effectiveness of SH with that of TH.

DESIGN

A large, open two-arm parallel-group pragmatic multicentre randomised controlled trial involving 32 UK hospitals and a within-trial cost-benefit analysis. A discrete choice experiment was conducted to estimate benefits (willingness to pay).

PARTICIPANTS

Patients with grades II-IV haemorrhoids who had not previously undergone SH or TH were included in the study.

INTERVENTIONS

Participants were randomised to receive either SH or TH. Randomisation was minimised at 1 : 1, in accordance with baseline EuroQol-5 Dimensions, three-level version (EQ-5D-3L) score, haemorrhoid grade, sex and centre, via an automated system.

MAIN OUTCOME MEASURES

The primary outcome was area under the quality-of-life curve measured using the EQ-5D-3L descriptive system over 24 months, and the primary economic outcome was the incremental cost-effectiveness ratio. Secondary outcomes included disease-specific quality of life, recurrence, complications, further interventions and costs.

RESULTS

Between January 2011 and August 2014, 777 patients were randomised (389 to receive SH and 388 to receive TH). There were 774 participants included in the analysis as a result of one post-randomisation exclusion in the SH arm and two in the TH arm. SH was less painful than TH in the short term. Surgical complications were similar in both arms. EQ-5D-3L score was higher for the SH arm in the first 6 weeks after surgery, but over 24 months the TH group had significantly better EQ-5D-3L scores (-0.073, 95% confidence interval -0.140 to -0.006; p = 0.0342). Symptoms and further interventions were significantly fewer in the TH arm at 24 months. Continence was better in the TH arm and tenesmus occurred less frequently. The number of serious adverse events reported was 24 out of 337 (7.1%) for participants who received SH and 33 out of 352 (9.4%) for those who received TH. There were two deaths in the SH arm, both unrelated to the eTHoS (either Traditional Haemorrhoidectomy or Stapled haemorrhoidopexy for haemorrhoidal disease) study. Patient preference did not seem to influence the treatment difference. SH was dominated by TH as it cost more and was less effective. The net benefit for the TH arm was higher than that for the SH arm.

LIMITATIONS

Neither the participants nor the assessors were masked to treatment assignment and final recruitment was slightly short of the total target of 800. There were also substantial missing follow-up data.

CONCLUSIONS

While patients who received SH had less short-term pain, after 6 weeks, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured TH. In addition, TH is cheaper. As part of a tailored management plan for haemorrhoids, TH should be considered over SH as the surgical treatment of choice for haemorrhoids refractory to clinic-based interventions.

FUTURE WORK

Perform an updated meta-analysis incorporating recently conducted European trials [eTHoS, HubBLe (haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids) and LingaLongo (Cost-effectiveness of New Surgical Treatments for Haemorrhoidal Disease)].

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80061723.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 70. See the NIHR Journals Library website for further project information.

Parental Preferences for the Organization of Preschool Vaccination Programs Including Financial Incentives: A Discrete Choice Experiment

Objective: To establish preferences of parents and guardians of preschool children for the organization of preschool vaccination services, including financial incentives. Design: An online discrete choice experiment. Participants: Parents and guardians of preschool children (up to age 5 years) who were (n = 259) and were not (n = 262) classified as at high risk of incompletely vaccinating their children. High risk of incomplete vaccination was defined as any of the following: aged less than 20 years, single parents, living in one of the 20% most deprived areas in England, had a preschool child with a disability, or had more than three children. Main Outcome Measures: Participant preferences expressed as positive (utility) or negative (disutility) on eight attributes and levels describing the organization of preschool vaccination programs. Results: There was no difference in preference for parental financial incentives compared to no incentive in parents "not at high risk" of incomplete vaccination. Parents who were "at high risk" expressed utility for cash incentives. Parents "at high risk" of incomplete vaccination expressed utility for information on the risks and benefits of vaccinations to be provided as numbers rather than charts or pictures. Both groups preferred universally available, rather than targeted, incentives. Utility was identified for shorter waiting times, and there were variable preferences for who delivered vaccinations. Conclusions: Cash incentives for preschool vaccinations in England would be welcomed by parents who are "at high risk" of incompletely vaccinating their children. Further work is required on the optimal mode and form of presenting probabilistic information on vaccination to parents/guardians, including preferences on mandatory vaccination schemes.

Implementing the communication for development strategy to improve knowledge and coverage of measles vaccination in western Chinese immunization programs: a before-and-after evaluation

Background

Communication for Development (C4D) is a strategy promoted by the United Nations Children’s Fund to foster positive and measurable changes at the individual, family, community, social, and policy levels of society. In western China, C4D activities have previously been conducted as part of province-level immunization programs. In this study, we evaluated the association of C4D with changes in parental knowledge of immunization services, measles disease, and measles vaccine, and changes in their children’s measles vaccine coverage.

Methods

From April 2013 to April 2014, C4D activities were implemented as part of provincial immunization programs in the Inner Mongolia, Guangxi, Chongqing, Guizhou, Tibet, Shaanxi, Gansu, Ningxia, and Qinghai provinces. We used a before-and-after study design and employed face-to-face interviews to assess changes in parental knowledge and vaccination coverage.

Results

We surveyed 2 107 households at baseline and 2 070 households after 1 year of C4D activities. Following C4D, 95% of caregivers were aware of the vaccination record check requirement for entry into kindergarten and primary school; 80% of caregivers were aware that migrant children were eligible for free vaccination; more than 70% of caregivers knew that measles is a respiratory infectious disease; and 90% of caregivers knew the symptoms of measles. Caregivers’ willingness to take their children to the clinic for vaccination increased from 51.3% at baseline to 67.4% in the post-C4D survey. Coverage of one-dose measles-containing vaccine (MCV) increased from 83.8% at baseline to 90.1% after C4D. One-dose MCV coverage was greater than 95% in the Guangxi, Shaanxi, and Gansu provinces. Two-dose MCV coverage increased from 68.5 to 77.6%. House-to-house communication was the most popular C4D activity among caregivers (91.6% favoring), followed by posters and educational talks (64.8 and 49.9% favoring).

Conclusions

C4D is associated with increased caregiver knowledge about measles, increased willingness to seek immunization services for their children, and increased measles vaccination coverage. Tailored communication strategies based on insights gained from these analyses may be able to increase vaccination coverage in hard-to-reach areas. C4D should be considered for larger scale implementation in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0261-y) contains supplementary material, which is available to authorized users.

A protocol for a cluster randomised feasibility study of an adolescent incentive intervention to increase uptake of HPV vaccination among girls

BACKGROUND

Uptake of the human papillomavirus (HPV) vaccine in the UK is good, but there are pockets of the community who remain unprotected. Immunisation teams usually require written parental consent for a girl to receive the vaccine. Evidence suggests that uptake of the vaccine might be improved by promoting consent form return (if returned, forms are likely to grant consent). Incentivising girls to return consent forms is a promising approach to promoting consent form return. Before testing the efficacy of an incentive intervention in a randomised controlled trial (RCT), we must first establish whether the RCT is feasible. In this randomised feasibility study, we aim to establish the feasibility of conducting a cluster RCT of an adolescent incentive intervention to increase uptake of HPV vaccination.

METHODS

At least six schools will be randomised to either an incentive intervention arm or a standard invitation arm. Girls in standard invitation arm schools will receive the usual HPV vaccine programme invitation materials. Girls attending schools in the incentive intervention arm will receive the standard invitation and will also be told that they will receive an incentive if they return their consent form (regardless of whether consent is granted or denied). The incentive is being entered into a prize draw to win a retail voucher. Feasibility objectives include estimating the schools' and parents' willingness to participate in the study and be randomised; response rates to questionnaires; the extent of missing data; the girls' and parents' attitudes towards the incentive offered; school staff experiences of participating, fidelity to the trial procedures, data on any unintended consequences and the possible mechanisms of action, and proof-of-concept evidence of the effect of the intervention on consent form return rates and uptake of the vaccine. Analysis of feasibility outcomes will primarily be descriptive. Consent form return rates and uptake of the vaccine will be presented by trial arm without comparison.

DISCUSSION

Incentivising HPV vaccine consent form return may promote HPV vaccine uptake. This study will provide the evidence needed to establish whether testing this incentive intervention using a RCT design in the future is feasible.

TRIAL REGISTRATION

ISRCTN72136061.

Acceptability of financial incentives for health behaviour change to public health policymakers: a qualitative study

Background

Providing financial incentives contingent on healthy behaviours is one way to encourage healthy behaviours. However, there remains substantial concerns with the acceptability of health promoting financial incentives (HPFI). Previous research has studied acceptability of HPFI to the public, recipients and practitioners. We are not aware of any previous work that has focused particularly on the views of public health policymakers.

Our aim was to explore the views of public health policymakers on whether or not HPFI are acceptable; and what, if anything, could be done to maximise acceptability of HPFI.

Methods

We recruited 21 local, regional and national policymakers working in England via gatekeepers and snowballing. We conducted semi-structured in-depth interviews with participants exploring experiences of, and attitudes towards, HPFI. We analysed data using the Framework approach.

Results

Public health policymakers working in England acknowledged that HPFI could be a useful behaviour change tool, but were not overwhelmingly supportive of them. In particular, they raised concerns about effectiveness and cost-effectiveness, potential ‘gaming’, and whether or not HPFI address the underlying causes of unhealthy behaviours. Shopping voucher rewards, of smaller value, targeted at deprived groups were particularly acceptable to policymakers. Participants were particularly concerned about the response of other stakeholders to HPFI – including the public, potential recipients, politicians and the media.

Overall, the interviews reflected three tensions. Firstly, a tension between wanting to trust individuals and promote responsibility; and distrust around the potential for ‘gaming the system’. Secondly, a tension between participants’ own views about HPFI; and their concerns about the possible views of other stakeholders. Thirdly, a tension between participants’ personal distaste of HPFI; and their professional view that they could be a valuable behaviour change tool.

Conclusions

There are aspects of design that influence acceptability of financial incentive interventions to public health policymakers. However, it is not clear that even interventions designed to maximise acceptability would be acceptable enough to be recommended for implementation. Further work may be required to help policymakers understand the potential responses of other stakeholder groups to financial incentive interventions.

Simulation study to determine the impact of different design features on design efficiency in discrete choice experiments

OBJECTIVES

Discrete choice experiments (DCEs) are routinely used to elicit patient preferences to improve health outcomes and healthcare services. While many fractional factorial designs can be created, some are more statistically optimal than others. The objective of this simulation study was to investigate how varying the number of (1) attributes, (2) levels within attributes, (3) alternatives and (4) choice tasks per survey will improve or compromise the statistical efficiency of an experimental design.

DESIGN AND METHODS

A total of 3204 DCE designs were created to assess how relative design efficiency (d-efficiency) is influenced by varying the number of choice tasks (2-20), alternatives (2-5), attributes (2-20) and attribute levels (2-5) of a design. Choice tasks were created by randomly allocating attribute and attribute level combinations into alternatives.

OUTCOME

Relative d-efficiency was used to measure the optimality of each DCE design.

RESULTS

DCE design complexity influenced statistical efficiency. Across all designs, relative d-efficiency decreased as the number of attributes and attribute levels increased. It increased for designs with more alternatives. Lastly, relative d-efficiency converges as the number of choice tasks increases, where convergence may not be at 100% statistical optimality.

CONCLUSIONS

Achieving 100% d-efficiency is heavily dependent on the number of attributes, attribute levels, choice tasks and alternatives. Further exploration of overlaps and block sizes are needed. This study's results are widely applicable for researchers interested in creating optimal DCE designs to elicit individual preferences on health services, programmes, policies and products.

Acceptability of Financial Incentives for Health Behaviours: A Discrete Choice Experiment

Background

Healthy behaviours are important determinants of health and disease, but many people find it difficult to perform these behaviours. Systematic reviews support the use of personal financial incentives to encourage healthy behaviours. There is concern that financial incentives may be unacceptable to the public, those delivering services and policymakers, but this has been poorly studied. Without widespread acceptability, financial incentives are unlikely to be widely implemented. We sought to answer two questions: what are the relative preferences of UK adults for attributes of financial incentives for healthy behaviours? Do preferences vary according to the respondents’ socio-demographic characteristics?

Methods

We conducted an online discrete choice experiment. Participants were adult members of a market research panel living in the UK selected using quota sampling. Preferences were examined for financial incentives for: smoking cessation, regular physical activity, attendance for vaccination, and attendance for screening. Attributes of interest (and their levels) were: type of incentive (none, cash, shopping vouchers or lottery tickets); value of incentive (a continuous variable); schedule of incentive (same value each week, or value increases as behaviour change is sustained); other information provided (none, written information, face-to-face discussion, or both); and recipients (all eligible individuals, people living in low-income households, or pregnant women).

Results

Cash or shopping voucher incentives were preferred as much as, or more than, no incentive in all cases. Lower value incentives and those offered to all eligible individuals were preferred. Preferences for additional information provided alongside incentives varied between behaviours. Younger participants and men were more likely to prefer incentives. There were no clear differences in preference according to educational attainment.

Conclusions

Cash or shopping voucher-type financial incentives for healthy behaviours are not necessarily less acceptable than no incentives to UK adults.

Acceptability of Parental Financial Incentives and Quasi-Mandatory Interventions for Preschool Vaccinations: Triangulation of Findings from Three Linked Studies

BACKGROUND

Childhood vaccinations are a core component of public health programmes globally. Recent measles outbreaks in the UK and USA have prompted debates about new ways to increase uptake of childhood vaccinations. Parental financial incentives and quasi-mandatory interventions (e.g. restricting entry to educational settings to fully vaccinated children) have been successfully used to increase uptake of childhood vaccinations in developing countries, but there is limited evidence of effectiveness in developed countries. Even if confirmed to be effective, widespread implementation of these interventions is dependent on acceptability to parents, professionals and other stakeholders.

METHODS

We conducted a systematic review (n = 11 studies included), a qualitative study with parents (n = 91) and relevant professionals (n = 24), and an on-line survey with embedded discrete choice experiment with parents (n = 521) exploring acceptability of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. Here we use Triangulation Protocol to synthesise findings from the three studies.

RESULTS

There was a consistent recognition that incentives and quasi-mandatory interventions could be effective, particularly in more disadvantaged groups. Universal incentives were consistently preferred to targeted ones, but relative preferences for quasi-mandatory interventions and universal incentives varied between studies. The qualitative work revealed a consistent belief that financial incentives were not considered an appropriate motivation for vaccinating children. The costs of financial incentive interventions appeared particularly salient and there were consistent concerns in the qualitative work that incentives did not represent the best use of resources for promoting preschool vaccinations. Various suggestions for improving delivery of the current UK vaccination programme as an alternative to incentives and quasi-mandates were made.

CONCLUSIONS

Parental financial incentives and quasi-mandatory interventions for increasing uptake of preschool vaccinations do not currently attract widespread enthusiastic support in the UK; but some potential benefits of these approaches are recognised.