Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research.

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.

Use of different bath grab bar configurations following a balance perturbation.

Although commonly prescribed, little research exists on bath grab bars. This study examined the use of bath grab bars following an experimentally induced balance perturbation, the influence of the task on grab bar use, and the influence of balance loss on acceptance of grab bars. A mixed design documented the use of four different grab bar configurations: (a) no bars, (b) vertical/horizontal combination, (c) L-shaped bar, and (d) vertical/angled combination following balance loss. Eighty adults were randomly assigned to three groups. Each group tried the "no bar" configuration and one of the other grab bar configurations. In 25% of the trials for each configuration, balance perturbation was induced. Older adults used grab bars 59.4% of time to regain balance, compared to 13.6% for younger adults. The vertical bar on the side wall was favored by both groups of participants during both bathtub entry and exit. To promote safety in the home, existing building codes must be revised to recommend minimally a vertical grab bar on the side wall. Additional bars may be needed to ensure safety during stand-to-sit and sit-to-stand phases of bath transfers. Initiatives must be taken to decrease the prejudice associated with grab bars.

Inadequate pain management during routine childhood immunizations: the nerve of it.

BACKGROUND: Immunization is regarded as one of the most significant medical achievements of all time. Recently, increasing attention has been paid to the pain resulting from routine childhood immunizations. OBJECTIVE: This narrative review summarizes existing knowledge about: (1) the epidemiology of childhood immunization pain; (2) the pain experience of children undergoing immunization; (3) current analgesic practices; (4) barriers to practicing pain management in children; and (5) recommendations for improvements in pain management during immunization. METHODS: We conducted a search of MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials for primary research and review articles published from inception of the databases through October 2008. Key search terms included immunization, pain, child/infant, vaccine, and intervention. Additional studies were identified through searches of the reference lists in the retrieved articles. No language restrictions were imposed regarding the type of article (eg, full article, abstract) or language. RESULTS: Vaccine injections are the most common iatrogenic procedure performed in childhood and a major source of distress for children (of all ages), their parents, and the participating health care professionals, as well as a direct cause of vaccine nonadherence. In addition, lack of adequate pain management during immunization exposes children to unnecessary suffering and the potential for long-term consequences, such as fear of needles. Numerous pain management strategies are available to reduce vaccine injection pain, including: (1) physical interventions and injection techniques; (2) psychological interventions; and (3) phar-macologic and combined interventions. However, adoption of pain-relieving techniques into clinical practice has been suboptimal. The underutilization of pain management strategies can be attributed to a lack of knowledge about pain and effective pain prevention strategies, and the persistence of attitudes about pain that interfere with optimal clinical practices. Current analgesic practices could be improved substantially if all stakeholders involved in immunization (eg, policy makers, practitioners, consumers) participate in efforts to reduce pain. Treating pain during childhood immunization has the potential to reduce distress during the procedure and greatly improve satisfaction with the immunization experience through more positive experiences for children and their families. Other potential benefits include improved adherence to immunization schedules and reduced sequelae of untreated pain. CONCLUSION: Immunization is a global health priority. Medical care can be improved if pain management becomes a routine aspect of the delivery of vaccine injections.

Development and validation of a modified falls-efficacy scale.

PURPOSE: This study examined the psychometric properties of a modified falls-efficacy scale (FES) that included more challenging activities of daily living items and made reference to the presence or absence of enabling assistive devices that are part of the built environment. METHOD: Baseline data from a longitudinal study among a cohort of 551 community-living seniors was used to generate data to inform the current report. Data for this study was collected in seniors' homes and apartments in two neighbouring cities in Canada, Ottawa and Gatineau. Measurements included a modified falls self-efficacy scale, various health and demographic measures. RESULTS: Factor analysis of the instrument revealed a two-factor solution, explaining 60.3% of the variance. The two emerging subscales were: Subscale 1--basic activities of daily living (ADLs), and subscale 2--challenging ADLs. The modified FES demonstrated greater internal consistency and better response variability than Tinetti's original FES. CONCLUSIONS: Adding more challenging ADL items and specifying use of assistive devices while undertaking the ADL may increase the FES' ability to distinguish between participants with varying degrees of mobility or health impairment. Recommendations for future research are offered and implications for use are discussed.

Access to bathtub grab bars: evidence of a policy gap.

This paper examines access to bathtub grab bars in privately and publicly owned apartment buildings and explores the profile of seniors who have access to bathtub grab bars. Results indicate that bathtub grab bars were significantly more prevalent in apartments that were publicly owned (91.3%) as compared to privately owned (37.8%) (p < 0.05). Results of a logistic regression for participants residing in non-universal-access buildings indicated that seniors were more likely to have grab bars in their bathtubs if they were older, were in poor health, had had a fall in the previous year, or used a mobility aid. Among those who did not have bathtub grab bars, 33 per cent reported fear of falling while bathing, 20 per cent reported difficulty bathing, and 23 per cent were found to have impaired balance. Findings are discussed in light of policy implications for universal access to grab bars, with apartment buildings being a logical place to start.

Do we have a knowledge transfer and translation plan at Teratogen Information Services?

Recently, a new field in science is emerging, which addresses the issue of ensuring that information that is generated from research, reaches the right people in the right format. This has been coined as knowledge transfer and translation and public health leaders worldwide are finding out ways to carry this out effectively. Ultimately, this should ensure greater investment in knowledge syntheses and transfer initiatives, that involve potential users of research to improve the quality of health for everyone. In this brief review/comment, an attempt will be made to help the readers understand the meaning of this new terminology and how it impacts Teratogen Information Services.

Through seniors' eyes: an exploratory qualitative study to identify environmental barriers to and facilitators of walking.

This qualitative exploratory study examined environmental factors influencing the walking choices of elderly people using the photovoice approach. A total of 13 seniors in Ottawa, Canada, took photographs of barriers to and facilitators of walking in their neighbourhoods. These photos were displayed during 3 focus-group sessions and served as touchstones for discussion. A total of 22 seniors, including 8 of the 13 photographers, participated in the focus-group sessions. The findings show that environmental hazards related to traffic and falls risks can be significant barriers to walking for seniors, and that connectivity can truly exist for the elderly only if convenience, hazard-free routes are available. They also indicate that simple amenities such as benches and washrooms might facilitate walking for seniors. A neighbourhood that is activity-friendly for seniors will also be a good place for everyone else to live, work, and play. The use of photovoice as a method was well received by the participants and provided rich information that may not have been captured through other means.

The prohibitive costs of accessing evidence online.

Delivering continuing education online involves making published materials available to learners. As part of a study that examined the use of the Internet for dissemination of information, permission to provide resources online was sought from 43 publishers, of whom 36 responded. Four (11.1%) denied permission to copy their materials. Seven (19.4%) granted permission to copy articles at no cost. The remaining 25 (69.4%) granted permission for a fee, ranging from dollar 2 to dollar 410 per article. These findings highlight a need for more accessible and cost-effective online resources to meet the challenges of evidence-based programs and practice in public health.

Development and evaluation of an instrument to measure seniors' attitudes toward the use of bathroom grab bars.

Bath grab bars can minimize the effects of many age-related deficits that may contribute to bath-related falls. Despite their potential value, bathroom safety devices remain largely underutilized by many community-living older adults and knowledge concerning attitudinal factors that influence the use of grab bars is sparse. This void of knowledge is due, at least in part, to the lack of instruments to measure the psychosocial constructs influencing bathroom safety device use. This study examined the psychometric properties of a newly developed Grab Bar Use Attitude scale (GUAS). Instrument formation, including item generation, evaluation by a panel of experts, and pilot testing of the draft instrument to establish its face and content validity, was followed by instrument validation using 546 community-living seniors. Results of principal components analysis of the GUAS revealed a two-factor solution, explaining 56% of the variance. The two constructs may best be described as functional/safety and psychosocial consequences of using grab bars. Psychometric analyses of the 9-item scale provided empirical evidence of the internal consistency of the total scale and each subscale. Finally, the GUAS distinguished between regular grab bar users and nonregular users. Implications for use are discussed.