1. 2 Commissioning Support for London Increasing MMR uptake - Proposed Approach to Stakeholder...

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Commissioning Support for London

Increasing MMR uptake -

Proposed Approach to Stakeholder Workshop

Including Output from Primary Care Giver

Workshops

19th August 2010

A partnership between The Information Centre for health and social care and Dr Foster Holdings LLP

FESC approved supplier

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Purpose

To share output from the 4 Primary Care Giver

Workshops in the context of a proposed structure

for the HCP Workshop on 23rd August, 2010.

To discuss and agree the structure and content.

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Context

Kensington & Chelsea

Higher SEG Workshop

Newham

Quantity of Ideas

Higher SEG Workshop

Lower SEG Workshop Lower SEG Workshop

Target 3 Workshop

Refined Intervention Ideas

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HCP Workshop Structure

2 ½ hours

Immediate task• Think of the last time you visited the dentist. What was good about it and what

was not so good?

Self Introduction • Name, role in relation to child immunisation • Response to Task

Set Context• About enhancing the child immunisation ‘journey’, specifically in relation to

MMR. Work conducted to date.

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Set Objective• To assess a range of ideas generated by primary care givers, to build on those

ideas and generate additional ones which can then be taken into further research.

Rules of Engagement• Every voice is equal• One voice at a time• No criticism by word, deed or facial expression

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What issues do our primary care givers have with the childimmunisation journey?

How they find out about itHow they get answers to their questionsThe experience of ‘the jab’

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Key General Findings

1. The only substantive differences between the higher and lower socio-economic groups were:

• The extent of their knowledge• The propensity to search out information, particularly online

2. Immunisation is a ‘distress purchase’

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3. It is emotionally charged

Fear and Anxiety in advance

They’re having to take important decisions, balancing risks with imperfect knowledge

“I didn’t know what to do to the point that I felt ill I was so worried”

Upset and Anger during the experience

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4. The experience feels brutal

It is as if their child is ambushed, then ‘pinned down’, ‘pinched’, ‘jabbed’ or ‘stabbed’

5. Their knowledge is imperfect

They generally struggled to list all the jabs, what diseases they were for and what were the potential consequences of those diseases.

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6. The barriers to MMR are many and varied

• It is not solely about Wakefield• the youngest are unaware of it• others are aware of it, appreciate it has either been discredited or

is media hype but it remains a lingering concern “the seed is planted and you’re afraid”

• It is a cocktail – 3 illnesses in one injection• There is imperfect understanding of what the three diseases are and

the health risks they carry• There is little experience of the three diseases but when there is it acts

as a positive spur• There is some experience of failure

“2 of my boys had their MMR – they had all their jabs – and they still got mumps – so I didn’t give it to my girl”

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6. The barriers to MMR are many and varied

• There are the odd myths – a belief breastfeeding will confer a mother’s immunity to the child.

• There is specific doubt about the follow up jab – is it really necessary?• Bad first time reactions “my daughter wasn’t well when she had her first jab and now I’m afraid to

give her the second”

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7. The barriers will only be overcome if….

• They are treated as emotional human beings, not ‘econ heads’. They need their feelings to be understood and validated.

• They can access clear, impartial, balanced information ideally independently of GP’s or the NHS who they believe have a vested interest in securing compliance.

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Issues

How do they find out about it?

With the first child it feels like an ambush

It takes them by surprise

“the first thing they (HCPs) do when the baby is born is stick ‘em with a needle...they stab ‘em...”

“literally straight away – they don’t even explain anything”

It is not a coherent programme about which they have been forewarned and for which they are prepared.

(But the degree to which they would be receptive to and engage with information in advance needs to be ascertained.)

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Issues

How do they get answers to their questions?

They have a myriad of potential sources but their primary needsare for validation of their concerns or anxieties and for impartiality.

Hence, online (particularly Higher SEG) and people close to them tend to be preferred

“You get more answers online than from the GP” “My mum supported me in not getting the jab – they didn’t really need it”

“I would go to the NHS but I always like to get a second opinion so I Google it or go on NetDoctor.”

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Issues


But both are problematic: those close have imperfect knowledge; online searches can intensify anxiety.

“I go online but have to stop myself because I’ll end up thinking I’ve got a blood clot travelling to my brain”

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Issues


Conversations with HCP’s are either avoided

“They’re just going to tell you you have to have it”

or of variable quality

“The nurse was dismissive, branded me as a nuisance mum”

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Issues

The experience of ‘the jab’

• Inflexible timing: appointment or drop in at restricted times• Child unfriendly surroundings• A rush• It can feel brutal – the child is ‘pinned down’ by the parent, their skin is

‘pinched’ and then they’re jabbed.

“Have to hold the child still and hold their head and then they stab them and the child is screaming”

• Mothers will cry, fathers feel angry, children are startled

“She looked at me as if to say ‘why are you doing this to me”

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Issues


• Variable quality of nurses, in terms of expertise and child friendliness

“The nurse weren’t friendly and now my little one’s got two scars where the jabs went – that put me off altogether”

• No influence over the ‘preparation’

“He sees ‘em preparing it and starts screaming”

• They feel very rushed afterwards– they don’t have time to get the baby dressed

“it’s a plaster on and GO!”

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Issues


• Aftermath is generally unpleasant

“she wasn’t really a crying baby but she really cried after that – it was traumatic”

“and then for the rest of the day you can tell he’s in pain”

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What issues do you have with the child immunisation journey?

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What ideas did primary care givers have?

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Ideas

What would be the best way to find out about jabs?

Before the birth

1. Face to Face

• At hospital appointments• Ante-natal class on subject (compulsory for 2nd time parents)• Pre-appointment with GP or at check-up• Meeting with other new parents in a facilitated group• In school curriculum – part of PHSE

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Ideas

What would be the best way to find out about jabs?

Before the birth

2. Communications• DVD – given during pregnancy• TV screens in ante-natal departments• TV channel (not subscription)• Written

• In Pregnancy book, but easy to read with more visuals• Emma’s Diary• NHS leaflet sent to home or in Bounty Pack

• Text• i-phone app• Website tutorial - e.g. on Bupa site

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Ideas

What would be the best way to have your questions answered?

• Moderated Group discussion• Interactive NOT a lecture• Led by health visitor/Midwife/nurse and GP

• On-line forum• Specialised jabs web-site - “injections made easy”• Fuller information in Red Book• An unbiased source:

• Miriam Stoppard• NSPCC

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Ideas

What would be the best way to have your questions answered?

• Pharmacist• Top supermarkets / Boots – stand for consultations• At Mothercare – meet an expert• Library• Imms helpline• Drugs approval authority

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Ideas

What would be a good conversation?

Show video extracts

What would be a bad conversation?

Show video extracts

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Ideas

Where would be best? • At home • Mobile unit – trailer/van/ambulance/blood bank/health van for kids• Specialised centre for immunisation (6 stars)• Children’s environments: playgroups, children’s centres, nursery,

school• Vaccination Party at someone’s house• An event: Teddy Bear’s Picnic, ‘Jab in the Park’ or ‘Jab Fest’• Pharmacy

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Ideas

Where would be best? • Supermarket / shopping mall• Libraries• Village halls• At an event – Newham ‘Under the Stars’• Health centre• Sports centre• Church / mosque / synagogue

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Ideas

Who could administer the jabs?

Familiar, friendly, reassuring• Midwives• Those who are likely to be most child friendly

• Screened nurses• Nursery nurse• Health visitor

• Community immunisation specialist• Parents, specifically Dads • Phlebotomist• Beautician with medical experience (1)• Health advisor• Pharmacist• Paramedics• Health care assistants

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Ideas

When would be best? • Greater flexibility to better suit working mothers and to allow for

partners to attend: evenings; early morning; weekends• Enable the making of appointments• When the child is older

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Ideas

How could the experience be better?

• A less ‘clinical’ environment – with toys, mobiles, colours, fish tank, TV showing children’s films to distract the child or calming music

• Show children’s idol having the jab – e.g. Dora the explorer / Ben Ten or Rory the Car

• Have a play worker to play with the child to help them relax before going in for the jab

• Have a more calming position for the child – not pinned down – to be shown (poster) or talked about in advance

• Options of:• A nurse to hold the baby• Take baby away so the parent is not there while being injected

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Ideas

How could the experience be better?

• Less painful ways of administering: liquid with milk; epi-pen; numb the area

• A freebie or sample on leaving (e.g. from the drug company)• Character transfer on plaster• Reward for the child e.g. lollipop • Telephone call to the parent 24 hours later to follow-up• Enable anonymous feedback

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Assessment of ideas against 3 suggested criteria:• Cost on a scale of 1-5 where 1 is inexpensive and 5 is extremely

expensive• Practicality on a scale of 1-5 where 1 is not difficult to implement and 5

is extremely difficult to implement• Likely effectiveness on a scale of 1-5 where 1 is not very likely to be

effective and 5 is extremely likely to be effective

Sheets, with ideas pre-listed in rows with blank columns for agreedcriteria, are handed out and completed

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Do you have additional ideas?

Based on all you have heard what is the best possible journey we couldcreate which we can then realistically test out with our primary caregivers?

Summarise

What we shall be doing next

Thanks

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Appendices

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HCP Workshop Structure2 ½ hoursImmediate task• (Think of the last time you visited the dentist. What was good about it and what was not so good?)Self Introduction • (name, role in relation to child immunisation) & Response to TaskSet Context• About enhancing the child immunisation ‘journey’, specifically in relation to MMR. Work conducted to date. Set Objective• To assess a range of ideas generated by primary care givers, to build on those ideas and generate additional ones

which can then be taken into further research.Rules of Engagement• Every voice is equal• One voice at a time• No criticism by word, deed or facial expression What issues do our primary care givers have with the child immunisation journey?• How they find out about it• How they get answers to their questions• The experience of ‘the jab’Findings from the workshops we conducted with primary care givers• Key general findings• IssuesWhat issues do you have with the child immunisation journey?What ideas did primary care givers have?• IdeasAssessment of ideas against 3 suggested criteria:• Cost on a scale of 1-5 where 1 is inexpensive and 5 is extremely expensive• Practicality on a scale of 1-5 where 1 is not difficult to implement and 5 is extremely difficult to implement• Likely effectiveness on a scale of 1-5 where 1 is not very likely to be effective and 5 is extremely likely to be effective• Sheets, with ideas pre-listed in rows with blank columns for agreed criteria, are handed out and completedDo you have additional ideas?• Based on all you have heard what is the best possible journey we could create which we can then realistically test out

with our primary care givers?• Summarise• What we shall be doing next• Thanks

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