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Introduction: We explored Canadian community pharmacists' perceptions of the CARD (Comfort Ask Relax Distract) system, a vaccine delivery framework that integrates evidence-based interventions that reduce immunization stress-related responses (ISRRs). The objective was to introduce CARD to pharmacists and obtain their feedback to guide future implementation efforts for community pharmacy-based vaccinations. Methods: Eighteen pharmacists across all provinces participated in one-on-one moderated virtual interviews. A semistructured interview guide was used to guide the discussion and included questions about experiences with coronavirus disease 2019 (COVID-19) vaccine administration and perceptions of CARD as a framework for vaccination delivery in the pharmacy. In this report, we focus on feedback about CARD. Interviews were audio-recorded and transcribed verbatim and deductively coded using the Consolidated Framework for Implementation Research (CFIR). Results: The study was conducted from May 28 to August 16, 2021. Pharmacists' responses were categorized in 3 CFIR domains: intervention characteristics, inner setting and characteristics of individuals. Overall, pharmacists were receptive towards CARD and thought it filled a current gap in practice, particularly for childhood vaccinations. Pharmacists reported learning techniques to make vaccinations more comfortable for their clients. They provided feedback on how specific interventions could be adapted for their practice (e.g., dissemination of client-directed education via appointment booking portals, provision of distraction items in waiting and vaccinating spaces). Discussion: This study provided preliminary evidence that pharmacists found CARD acceptable and appropriate for community pharmacy-based vaccinations. The data collected from this study were used to inform a small-scale implementation project with CARD during COVID-19 vaccine administration in children aged 5 to 11 years.
ABSTRACT
BACKGROUND: Pain and fear during immunizations can affect children and their future behaviour toward immunization. These negative experiences can be amplified when children receive vaccines as part of school-based immunization programs, where parental or tutor supports are missing. In 2015, HELPinKIDS&ADULTS, a Canadian network of experts, published a clinical practice guideline (CPG) on the management of pain and fear during immunization. This guideline has been endorsed by international, national and provincial organizations. However, the level of integration and implementation of the CPG into local and community immunization programs such as school-based immunization clinics is unclear. METHODS: An investigation whether public health units in Ontario integrated and implemented the pain and fear interventions recommended by the CPG into school-based immunization policies and practices was concluded. RESULTS: The study shows that the majority of public health units do have pain and fear policies and procedures in place, but interventions are not integrated in a consistent and formal manner, leading to suboptimal uptake of interventions during immunizations at school. CONCLUSION: For pain interventions to be applied with sufficient fidelity and in enough individuals to have a meaningful effect, organizational leaders need to create directives and procedures that support implementation in a systematic and accountable manner.
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OBJECTIVE: Pain, fear, and fainting management during school-based vaccinations is suboptimal. The objective was to examine stakeholder perceptions of barriers and facilitators to better practices. Method: Six semi-structured focus groups were conducted in Niagara Region, Ontario: two parent groups (n=7); one grade 7 to 8 student group (n=9); two nurse groups (n=12); and one school staff group (n=6). Participants shared perceptions about school vaccination clinics and the implementation of specific strategies and tools. Focus groups were audio recorded and transcribed. The Consolidated Framework for Implementation Research (CFIR) was used as the framework for analysis. RESULTS: Feedback from stakeholders was categorized into four domains of CFIR: intervention characteristics, inner setting, outer setting, and characteristics of individuals. Intervention characteristics included: vaccine educational materials, vaccination accommodations, distraction techniques, topical anaesthetics, and food. Inner setting factors included: school vaccination procedures, relationships between school staff and nurses, assessment and documentation of student fear, and factors that contribute to a chaotic vaccination clinic. Outer setting factors were: the social environment and addressing parent and student needs. Stakeholder roles were discussed in characteristics of individuals. CONCLUSION: This study identified elements that can facilitate and challenge pain and fear mitigation tools and strategies; these elements should be considered in the development of a Knowledge Translation (KT) intervention to improve the school vaccination experience.
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OBJECTIVE: School-based vaccination programs can be a source of distress for many students due to the pain from the needle injection and related fears. We created a multifaceted Knowledge Translation (KT) intervention to address vaccination and pain, fear, and fainting called The CARD™ System. The objectives were to document acceptability of key tools included in the multifaceted KT intervention and their effectiveness in improving knowledge and attitudes about vaccination pain and fear. METHODS: Quantitative and qualitative methods were used. Students, school staff, public health nurses, and parents participated in separate focus groups whereby they independently completed a knowledge and attitudes survey and provided structured and qualitative feedback on key KT tools of the multifaceted KT intervention. They then repeated the knowledge and attitudes survey. RESULTS: Altogether, 22 students (grade 6 and 7), 16 school staff (principals, grade 7 and 8 teachers, resource teachers, secretaries), 10 nurses (injecting, charge, and school nurses), and 3 parents participated. Knowledge test scores increased post-KT tool review: 8.5 (2.1) versus 7.3 (1.9); P<0.001. Attitudes were more positive about the individual nature of pain and fear experience during vaccination. Student fear scores were lower post-tool review: 5.1 (2.9) versus 4.6 (3.0); P<0.001. The majority of the participants reported they understood all the information, the amount was just right and that the information was useful. DISCUSSION: The KT tools were demonstrated to be acceptable and to improve knowledge. Future research is warranted to determine their impact on student experience during school vaccinations.
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OBJECTIVE: Many students are fearful of vaccine injection-associated pain. In prior research, we created Knowledge Translation (KT) tools to address school vaccinations and associated pain, fear, and fainting. The objectives of this pilot implementation project were to determine the acceptability and impact of these KT tools on student knowledge, attitudes, and perceptions of their vaccination experience. METHODS: Pre-post mixed methods design. Students in an independent school in the Greater Toronto Area, Ontario, participated in two separate focus groups before and after school vaccinations. In both sessions, they independently completed a knowledge and attitudes survey, reviewed three KT tools (two videos and one pamphlet) and then repeated the knowledge and attitudes survey. They provided structured and qualitative feedback about the KT tools and described the impact of the education on the vaccination experience. RESULTS: Altogether, 11 grade 7 students participated. Knowledge scores were higher post-tool review compared to baseline in the first focus group. There was no significant difference in fear scores and attitudes about getting vaccinated. Qualitative feedback was categorized into two themes: intervention characteristics and characteristics of the school environment. Students reported the KT tools helped them to prepare for vaccination. They used the information on vaccination day to reduce their own fear and pain and to assist peers. They believed all students should view the KT tools. Students reported that teachers and nurses did not do enough to make vaccinations a positive experience. For example, they did not provide a private setting as an option for vaccination and prevented them from using some coping strategies recommended in the KT tools. DISCUSSION: This study provides preliminary evidence of the acceptability and positive impact of the KT tools on students' vaccination experiences. Future research is recommended that involves inclusion of all students and adults in the KT intervention.
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BACKGROUND: Many students are afraid of receiving vaccinations at school. We implemented a novel, multifaceted knowledge translation intervention incorporating evidence-based vaccination coping strategies-The CARD™ System (C-Comfort, A-Ask, R-Relax, D-Distract)-and evaluated impact on student attitudes, knowledge, coping strategies used, and symptoms during school-based vaccinations. METHODS: Mixed methods. Ten schools participated in a controlled clinical trial: five experimental and five control. Experimental School (ES) students completed a knowledge and attitudes survey during an in-class CARD™ educational session prior to school vaccinations and selected coping strategies for upcoming vaccinations. Control School (CS) students received the usual vaccine education lesson, which did not include information about or selection of coping strategies. At all schools and during both vaccination clinic visits (fall and spring), injecting nurses recorded specific coping strategies used, and students independently rated their fear, pain, and dizziness during vaccinations. Focus groups were conducted at five schools after all clinics were completed (three ES, two CS). RESULTS: ES students had higher knowledge (P<0.001), less fear (P=0.03), and greater willingness to be vaccinated (P=0.001) after the in-class education session. Students rated the education as understandable, sufficient, useful, and that it prepared them for vaccinations. During school vaccination clinics, ES students selected more coping interventions than CS students. There were fewer students with high levels of fear (P=0.008) and dizziness (P=0.04) in the ES group. In round 2, fewer students (P=0.02) in the ES group returned to the clinic postvaccination because they were feeling unwell. ES students participating in focus groups scored higher on their knowledge test (P<0.001) compared with CS students and reported learning and benefitting from CARD™. DISCUSSION: This small-scale implementation study provides preliminary evidence of the effectiveness of CARD™ in improving vaccination experiences for students at school. Future research is recommended that examines CARD™ in different settings to confirm these results.
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OBJECTIVE: We conducted a small-scale implementation study that integrated The CARD™ System (C-Comfort, A-Ask, R-Relax, D-Distract)-a multifaceted knowledge translation intervention designed to improve the vaccination experience at school-within the school vaccination program. METHODS: Mixed methods design, including a controlled clinical trial and focus group interviews. The experimental group included five schools whereby CARD™ was implemented. The control group included five schools whereby no changes were made. Focus groups were held at the end of the school year. For nurses trained in CARD™, additional focus groups were held at CARD™ training and after the first round of vaccine clinic visits. Outcomes included vaccination rate at school and adult stakeholder perceptions. RESULTS: Altogether, 323 students attended study schools. Fifty-five nurses, school staff, and parents participated in 15 focus groups. The school vaccination rate did not differ (P>0.05) between groups for round 1 clinics (76% versus 77%) or round 2 clinics (68% versus 70%). Participants reported acceptability, appropriateness, feasibility, and satisfaction with CARD™. Experimental group nurses were able to integrate CARD™ within usual activities, including clinic planning, student education, and clinic-day set-up and student vaccinations. Students in experimental schools were described by nurses and school staff as more prepared and less fearful during vaccinations. Nurses reported that CARD™ built on their practice; they had higher confidence in their ability to assess pain and fear and higher satisfaction with their ability to manage it. Nurses also reported improved collaboration with students and with each other. All stakeholder groups recommended continuing CARD™. Some additional time was required, primarily related to clinic planning activities and data collection for study purposes. CONCLUSION: CARD™ is a promising new approach for improving the delivery of vaccinations at school. Exploration of approaches to increase parental reach and monitoring of vaccination uptake rate over time are recommended.
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Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.