Why do parents not re-vaccinate their child for influenza? A prospective cohort study

Child influenza vaccination rates for the UK are published annually, however there are no publicly available data on how many children are re-vaccinated the following year. This prospective cohort study aimed to identify factors associated with not re-vaccinating one’s child. Participants (n = 270) completed a questionnaire before their child was vaccinated for influenza in the 2016/17 season, and follow-up questionnaires three days and one month after their child’s vaccination. Re-vaccination data were collected at the end of the 2017/18 influenza season (n = 232, response rate 85.9%). Forty-one children (17.7%) were not re-vaccinated for influenza in 2017/18. Parental report of severe side-effects three days after vaccination (p = .04) and worry about side-effects one month after vaccination (p = .05) were associated with not re-vaccinating. However, the restricted sample size reduced the statistical power of these analyses. Decreasing parental worry about side-effects may help improve re-vaccination rates.Clinical trial registration: The study was registered on ClinicalTrials.gov (NCT02909855).     

Why do patients and families request transfers to tertiary care? a qualitative study

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.     

Is annual vaccination best? A modelling study of influenza vaccination strategies in children

IntroductionAnnual vaccination of children against influenza is a key component of vaccination programs in many countries. However, past infection and vaccination may affect an individual’s susceptibility to infection. Little research has evaluated whether annual vaccination is the best strategy. Using the United Kingdom as our motivating example, we developed a framework to assess the impact of different childhood vaccination strategies, specifically annual and biennial (every other year), on attack rate and expected number of infections.Methods and findingsWe present a multi-annual, individual-based, stochastic, force of infection model that accounts for individual exposure histories and disease/vaccine dynamics influencing susceptibility. We simulate birth cohorts that experience yearly influenza epidemics and follow them until age 18 to determine attack rates and the number of infections during childhood. We perform simulations under baseline conditions, with an assumed vaccination coverage of 44%, to compare annual vaccination to no and biennial vaccination. We relax our baseline assumptions to explore how our model assumptions impact vaccination program performance.At baseline, we observed less than half the number of infections between the ages 2 and 10 under annual vaccination in children who had been vaccinated at least half the time compared to no vaccination. When averaged over all ages 0–18, the number of infections under annual vaccination was 2.07 (2.06, 2.08) compared to 2.63 (2.62, 2.64) under no vaccination, and 2.38 (2.37, 2.40) under biennial vaccination. When we introduced a penalty for repeated exposures, we observed a decrease in the difference in infections between the vaccination strategies. Specifically, the difference in childhood infections under biennial compared to annual vaccination decreased from 0.31 to 0.04 as exposure penalty increased.ConclusionOur results indicate that while annual vaccination averts more childhood infections than biennial vaccination, this difference is small. Our work confirms the value of annual vaccination in children, even with modest vaccination coverage, but also shows that similar benefits of vaccination may be obtained by implementing a biennial vaccination program.Author summaryMany countries include annual vaccination of children against influenza in their vaccination programs. In the United Kingdom (UK), annual vaccination of children aged of 2 to 10 against influenza is recommended. However, little research has evaluated whether annual vaccination is the best strategy, while accounting for how past infection and vaccination may affect an individual’s susceptibility to infection in the current influenza season. Prior work has suggested that there may be a negative effect of repeated vaccination. In this work we developed a stochastic, individual-based model to assess the impact of repeated vaccination strategies on childhood infections. Specifically, we first compare annual vaccination to no vaccination and then annual vaccination to biennial (every other year) vaccination. We use the UK as our motivating example. We found that an annual vaccination strategy resulted in the fewest childhood infections, followed by biennial vaccination. The difference in number of childhood infections between the different vaccination strategies decreased when we introduced a penalty for repeated exposures. Our work confirms the value of annual vaccination in children, but also shows that similar benefits of vaccination can be obtained by implementing a biennial vaccination program, particularly when there is a negative effect of repeated vaccinations.     

Why do health and social care providers co-operate?

Within Europe, although there are numerous examples of poor co-ordination in the delivery of integrated care, many providers do co-operate. We wanted to know why providers are moved to co-operate. In terms of systematic research, this is a new field; researchers have only begun to theorise about the rationales for co-operation. Practically, the issue of achieving co-operation attracts much attention from policymakers. Understanding the reasons for co-operation is a prerequisite for developing effective policy in support of integrated care. Our aim is to explore the comparative validity of different theoretical perspectives on the reasons for co-operation, to indicate directions for further study and for policy making. We used data from three successive studies to perform pattern matching with six established theoretical perspectives: transaction costs economics, strategic choice theory, resource dependence theory, learning theory, stakeholder theory and institutional theory. Insights from the studies were compared for validating purposes (triangulation). The first study concerned the evaluation of the Dutch 'National Home Health Care Programme' according to the case study methodology. The second and third studies were surveys among project directors: questionnaires were based on the concepts derived from the first study. Researchers should combine normative institutional theory, resource dependence theory and stakeholder theory into one perspective, in order to study relationship formation in health and social care. The concept of institutions (rules) is the linchpin between the theories. Policy makers must map the institutions of stakeholders and enable integrated care policy to correspond with these institutions as much as possible.     

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice

Background

While in general practice chronic non-specific abdominal complaints are common, there is insufficient data on the clinical course and the management of these complaints. Aim of this study was to present a primary care based profile of these chronic complaints including health care involvement, health status and clinical course.

Methods

Thirty general practitioners (GPs) and patients from their practices participated in a prospective follow-up study. All patients and GPs were asked to complete questionnaires at baseline and at 6, 12 and 18 months of follow-up. The GPs provided information on diagnostic and therapeutic management and on referral concerning 619 patients with chronic non-specific abdominal complaints, while 291 patients provided information about health status and clinical course of the complaints.

Results

When asked after 18 months of follow-up, 51,7% of the patients reported an equal or worsened severity of complaints. General health perception was impaired and patients had high scores on SCL-anxiety and SCL-depression scales. Diagnostic tests other than physical examination and laboratory tests were not frequently used. Medication was the most frequent type of treatment. The persistence of chronic non-specific abdominal complaints was quite stable.

Conclusion

Once non-specific chronic abdominal complaints have become labelled as chronic by the attending physician, little improvement can be expected. The impact on patients' physiological and psychological well-being is large. GPs use a variety of diagnostic and therapeutic strategies. Research into the evidence base of currently applied management strategies is recommended.     

What do children observe and learn from televised sports betting advertisements? A qualitative study among Australian children

Objective : To explore children's awareness of sports betting advertising and how this advertising may influence children's attitudes, product knowledge and desire to try sports betting. Methods : Semi‐structured qualitative interviews were conducted with 48 children (8–16 years) from Melbourne, Victoria. The interview schedule explored children's recall and interpretations of sports betting advertising, strategies within advertisements that may appeal to children, children's product knowledge and understanding of betting terminology, and factors that may encourage gambling. Interviews were transcribed and thematic analysis was conducted. Results : Children recalled in detail sports betting advertisements that they had seen, with humour the most engaging appeal strategy. They were also able to describe other specific appeal strategies and link these strategies to betting brands. Many children described how advertisements demonstrated how someone would place a bet, with some children recalling the detailed technical language associated with betting. Conclusions : Children had detailed recall of sports betting advertisements and an extensive knowledge of sports betting products and terminology. Implications for public health : To protect children from the potential harms associated with sports betting, governments should consider changing regulations and implementing evidence‐based education campaigns to counter the positive messages children receive from the sports betting industry.     

Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement

Background

Despite evidence-based guidelines, aspirin prescribing for the secondary prevention of stroke is sub-optimal. Little is known about why general practitioners do not prescribe aspirin to indicated patients. We sought to identify and describe factors that lead general practitioners (GPs) not to prescribe aspirin to eligible stroke patients. This was the first stage of a study exploring the need for and means of improving levels of appropriate aspirin prescribing.

Method

Qualitative interviews with 15 GPs in the West Midlands.

Results

Initially, many GPs did not regard their prescribing as difficult or sub-optimal. However on reflection, they gave several reasons that lead to them not prescribing aspirin for eligible patients or being uncertain. These include: difficulties in applying generic guidelines to individuals presenting in consultations, patient resistance to taking aspirin, the prioritisation of other issues in a time constrained consultation and problems in reviewing the medication of existing stroke patients.

Conclusion

In order to improve levels of appropriate aspirin prescribing, the nature and presentation risk information available to GPs and patients must be improved. GPs need support in assessing the risks and benefits of prescribing for patients with combinations of complicating risk factors, while means of facilitating improved GP-patient dialogue are required to help address patient uncertainty. A decision analysis based support system is one option. Decision analysis could synthesise current evidence and identify risk data for a range of patient profiles commonly presenting in primary care. These data could then be incorporated into a user-friendly computerised decision support system to help facilitate improved GP-patient communication. Measures of optimum prescribing based upon aggregated prescribing data must be interpreted with caution. It is not possible to assess whether low levels of prescribing reflect appropriate or inappropriate use of aspirin in specific patients where concordance between the GP and the patient is practised.

     

Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data

Depression in older people is common, under-recognised and often undertreated. This study aimed to explore the reasons why older people with depression may not present to primary care. Secondary analysis was carried out, of qualitative data collected in two previous studies in North-West England. Older people are reluctant to recognise and name 'depression' as a set of symptoms that legitimises attending their general practitioner (GP). They do not consider themselves candidates for help for their distress. This is partly due to perceptions of the role of the GP but also to previous negative experiences of help seeking. In addition, treatments offered, which are predominantly biomedical, may not be acceptable to older people. Interventions offered to older people need to encourage social engagement, such as befriending, and enhancement of creative, physical and social activity.     

What influences elderly peoples' decisions about whether to accept the influenza vaccination? A qualitative study

Influenza and its related illnesses remain a major cause of preventable morbidity and mortality in the elderly worldwide. The current influenza vaccine campaign in the UK is only a partial success despite annual costly publicity campaigns. The aim of this study was to explore the influences on decision making by elderly people for influenza vaccine uptake. Twenty patients age 75 years and over were purposively selected from those eligible for influenza vaccination in an inner city general practice in England. In-depth qualitative interviews were conducted with 10 patients who accepted and 10 who refused the vaccine. Those interviewed were concerned about maintaining their health, and had a good understanding of influenza, its transmission and prevention. The decision whether to accept or refuse the influenza vaccination was influenced by trust or mistrust of modern medicine, prior experience of vaccination and perceived risk from influenza. Newly acquired lay experience and personal perceived risk from influenza seemed to be more important catalysts for the change in vaccination uptake than professional recommendation or advertising by official government health agencies. In order to improve uptake rates, the official message promoting vaccine uptake needs to take more account of lay knowledge and the subjective assessment of risk.     

Why do patients discontinue antidepressant therapy early? A qualitative study

Background: Current guidelines for antidepressant prescribing are that treatment should be continued following the resolution of symptoms: six months after a first episode and for at least two years for those with previous episodes. Despite this, sub-optimal treatment duration still predominates. Patients have negative and positive views on antidepressants, which change throughout their treatment journey.

Objectives: To explore views and experiences of patients recently initiated on antidepressants (within six months), and to consider the influences on early discontinuation.

Methods: A qualitative interview study was used in four general practices in the North East of Scotland. A purposive sample of primary care patients, newly initiated on antidepressants, was interviewed to explore views and experiences with antidepressant therapy. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted using a consensus coding frame developed by two researchers.

Results: Twenty-nine patients participated. Three main factors influencing discontinuation were identified: ownership, knowledge and support. The treatment journey was characterized by four important time points where health care intervention may be helpful.

Conclusion: Health care professionals would benefit from exploring patient knowledge and views on depression and antidepressants at an early stage in treatment. Patients would welcome active involvement in treatment decision making, the provision of information and ongoing support.     

Models of service support for parents of disabled children. What do we know? What do we need to know?

Research carried out over a number of years provides a consistent picture of the experiences and needs of parents of disabled children. Recent studies, based on models of stress and coping, have identified factors which relate to high or low levels of parental distress. Whilst this research can provide useful information for service development, there appears to have been little change over the years in parents' reports of unmet need. It is clear that parental need covers a wide range of aspects of family life and holistic models of service support are required. Although evaluation studies which identify models of services that can change this situation are few, there are positive examples of models of support. The paper reviews the findings of such evaluation and identifies a number of important characteristics of effective service models.     

Why do not patients receive influenza vaccine in December and January?

BACKGROUND: Influenza vaccination levels in older patients have changed little since the mid-1990s. Despite frequent health care visits by a majority of older persons, many missed opportunities continue to occur. METHODS: Patients were eligible for the study if they were age 50 and older, had not received influenza vaccine during the current season and were making a scheduled visit to one of the 13 study sites in California, New York, or New Mexico for purposes other than vaccination. Through direct observation, we determined if office staff inquired about vaccination status, discussed vaccination, or both. We defined missed opportunities as failure to administer influenza vaccine to patients for whom it was indicated. RESULTS: Missed opportunities increased steadily from October to January (P < 0.0001), and were more common when there was no inquiry or discussion (P < 0.00001), among patients aged 50-64 (P < 0.0001) and in California and New Mexico (P = 0.001). A classification tree analysis revealed that lack of inquiry and week of visit contributed most to missed opportunities. DISCUSSION: Early in the vaccination season, missed opportunities were uncommon and specific inquiries into or discussion of vaccination did not appear necessary. In December and January, patients tended to be vaccinated only when vaccination was addressed during the visit. Efforts to remind patients about vaccination later in the vaccination season may be essential to achieving higher coverage in the U.S.     

Differential access to health care and support? A qualitative analysis of how Australian smokers conceptualise and respond to stigma

Scholarship on stigma, originally theorised as a ‘mark’ of social disgrace or difference, has since moved away from individual-level analyses to consider the socio-cultural context in the ‘marking’ of groups of people. In response to this theoretical shift, scholars have demonstrated how extensive tobacco denormalisation policies have contributed to the stigmatisation of smokers, documenting smokers’ experiences of stigma across a number of developed countries. We extend this analysis to the Australian context, examining smokers’ constructions of stigma and their reactions to policies that would give smokers differential access to healthcare. Based on 29 interviews with Australian smokers, we focus on what constitutes evidence of stigma and how participants use social comparisons to respond to stigma. We then explore an assumption underpinning participants’ accounts of stigma: that only smokers committed to cessation are ‘deserving’ of treatment. We close by discussing theoretical perspectives and opportunities in stigma research and the need to extend a stigma lens to study emerging public health issues, such as electronic cigarettes.